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Page 4 of 9 Somers et al. Vessel Plus 2024;8:15 https://dx.doi.org/10.20517/2574-1209.2023.48

Outcomes
The primary outcomes of the study are surgical mortality and new permanent neurological damage.
Secondary outcomes are acute kidney injury, postoperative dialysis, postoperative wound infection (either
sternal or groin), and reintervention for bleeding or post-dissection aneurysm at follow-up.

Surgical mortality is defined as in-hospital mortality (all-cause death occurred during primary
hospitalization) plus 30-day mortality (all-cause death including after discharge, but within 30 days of
primary surgery). New permanent neurological damage is defined as any neurological symptoms that were
not present during presentation prior to surgery but occurred after surgery and were still present at
discharge. AKI is defined by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines .
[20]
Sternal wound or groin infection were defined as any infection requiring antibiotics and/or positive
cultures. Reintervention for bleeding is any intervention, either pericardiocentesis, subxiphoid
pericardiotomy, or resternotomy, indicated to treat pericardial effusion.

Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics 27.0 (IBM Corp, Armonk, NY) statistical
software. Continuous variables are expressed as mean ± standard deviation, and categoric variables as
counts and percentages. Fisher’s exact test, the χ2 test, and independent students t-test were used for
univariate analysis. Logistic regression models were used for multivariate analyses including the variables
age, sex, preoperative tamponade, preoperative neurological damage, SCAR with or without clamp, root
repair, arch repair, bypass time, clamp time, deep hypothermic cardiac arrest (DHCA) duration, ASCP use
and ASCP duration, and arterial cannulation approach (DA vs. FA). FA cannulation was used as a reference
category. Propensity score matching was performed based on sex, age above 60, ECC time of more than
180 min, unilateral or bilateral cerebral perfusion, and preoperative shock based on previous literature [21-23] .
Statistical significance was considered at a P-value of < 0.05.

RESULTS
A total of 281 consecutive patients underwent ATAAD surgery at our center from January 2006 to
December 2022. Seven patients were excluded from the analysis, as they died before initiation of
extracorporeal circulation (N = 3) or underwent primary RAX cannulation (N = 4). A total of 274 patients
remained for final analysis. The mean age was 62.5 ± 12.5 years, and 43.8% were female [Table 1].
Preoperative tamponade was significantly more present in patients who underwent FA than DA
cannulation (P = 0.033). The baseline characteristics of all patients are shown in Table 1. Looking more
closely into patients who died prior to initiating cannulation reveals all patients died due to aortic rupture
after the slow release of sudden tamponade through sternotomy. In one patient, femoral cannulation was
initiated, but due to profuse blood loss, it remained impossible to run adequate circulation.

DA cannulation was used in 129 patients (47.1%) and another 145 patients (52.9%) received FA cannulation.
Over the last few years, the number of DA cannulation cases has increased compared to FA cannulation.
During surgery, the cannulation strategy changed from DA to FA in three cases (2.1%) and from FA to DA
in three cases (2.3%). The major reason for the change from FA to DA was the inability to introduce the
guidewire or cannula in the femoral artery. The decline or loss of right-sided radial blood pressure or
INVOS after aortic cross-clamping was the major reason for the change from DA to FA.

Most patients who received a root-sparing technique also underwent aortic valve intervention, either by
replacement (10/179, 5.6%) or resuspension (107/179, 59.8%). There were no significant differences between
DA and FA cannulation on aortic valve repair. Root replacements, particularly the Bentall procedure, were