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Page 2 of 9 Somers et al. Vessel Plus 2024;8:15 https://dx.doi.org/10.20517/2574-1209.2023.48

Conclusion: DA cannulation offers a safe and fast alternative to FA cannulation in ATAAD surgery. There were no
significant differences in mortality and neurological complications. Future studies should focus on the differences
between RAX and DA cannulation strategies on postoperative outcomes in ATAAD surgery.

Keywords: Type A dissection, cannulation, axillary artery, direct aorta, femoral artery, extracorporeal circulation

INTRODUCTION
Acute type A aortic dissection (ATAAD) surgery continues to have significant morbidity and mortality
[1-3]
rates, despite improved operative techniques over the past decades . This includes 18% new neurological
complications and surgical mortality rates of 17%-22%, which are mostly related to organ malperfusion (e.g.,
cerebral, renal, or spinal ischemia) [1,4-7] . Optimal intraoperative organ perfusion can therefore improve
ATAAD surgical outcomes.

Femoral artery (FA) cannulation has long been the primary choice for its quick and easy access. This is
especially relevant in hemodynamically unstable patients. FA cannulation is, therefore, still used in 28%-46%
of the ATAAD cases [2,8-11] . However, retrograde flow may cause organ malperfusion, cerebral embolization,
[12]
and potentially early dilatation of the false lumen . Therefore, cannulation of the right axillary artery
(RAX) with antegrade flow downstream has been increasingly encouraged and advocated to be associated
with a significantly lower risk of mortality and stroke compared to FA cannulation in multiple studies and
meta-analyses [13-16] . As such, current guidelines advocate the use of RAX cannulation in stable patients above
peripheral (femoral) cannulation [7,17] . However, RAX cannulation is often unfamiliar territory for most
cardiac surgeons, and can also be technically challenging and time-consuming, particularly important in
emergency settings.

Another modality to ensure antegrade downstream perfusion is direct aortic (DA) cannulation in the
ascending aorta [4,18,19] . Obviously, this is the routine cannulation location for the large majority of cardiac
procedures, and all cardiac surgeons are familiar with this technique. In the guidelines, it carries the same
recommendation class as RAX cannulation (class IIa recommendation) . However, manipulation and
[17]
cannulation in the acutely dissected aorta might instigate reluctancy to utilize this technique. According to a
survey among cardiac surgeons in European centers, only 6% of surgeons prefer DA cannulation as their
[11]
first choice in the acute setting . Furthermore, published data on the safety of this technique are limited.
The available reviews and meta-analyses preferentially compare FA with RAX cannulation, and only a
minority of the included studies use DA cannulation [13-15] . At our center, DA cannulation is used frequently
in ATAAD; therefore, we describe our 17-year experience of ATAAD surgery and compare direct (aortic)
cannulation with femoral cannulation regarding postoperative mortality and neurological complications.

METHODS
We performed a retrospective single-center cohort study of patients who underwent ATAAD surgery in the
Radboud University Medical Center, Nijmegen, the Netherlands, between January 2006 and January 2023.
Patients who died before initiation of extracorporeal circulation were excluded from the analysis. Medical
records from all remaining patients were retrospectively reviewed.

Surgical technique
All surgeries were performed by a dedicated aortic surgical team, by either a dedicated aortic surgeon or an
experienced cardiac surgeon. The decision for FA or DA cannulation lies with the surgeon, primarily based
on experience and preference and after careful examination of preoperative CTA. All patients were opened