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Page 6 of 9 Somers et al. Vessel Plus 2024;8:15 https://dx.doi.org/10.20517/2574-1209.2023.48

with AKI who required dialysis (P = 0.093 and P = 0.561, respectively). Groin infections were reported in
2.1% of the FA group. No leg ischemia was observed after FA cannulation. All other postoperative
characteristics are shown in Table 2. Preoperative tamponade was significantly more present in the FA
cannulation group, although surgical mortality did not differ significantly within this subgroup (3/18 for
DA and 8/35 for FA; P = 0.730). The multivariate analyses for DA canulation were computed using the
baseline characteristics and the operative variables as described before, with FA cannulation as the reference
category. Permanent new neurological damage (OR 1.518, 95%CI: 0.553-4.167, P = 0.418) and surgical
mortality (OR 0.671, 95%CI: 0.244-1.844, P = 0.439) were equally distributed between DA and FA.

Seventy-one patients from femoral cannulation were matched with a similar number of direct aortic
cannulation patients. Only reintervention > 48 h after primary intervention was significantly different,
favoring femoral cannulation (8 vs. 20; P = 0.011).

The median follow-up was 52 months (range 0-193 months). In this follow-up period, there were no
significant differences in reoperations between DA and FA, nor significant differences in diameter of the
post-dissection descending aorta (see Table 3).

DISCUSSION
This study suggests DA cannulation is a safe alternative to FA cannulation in the surgical treatment of
ATAAD patients, offering similar postoperative mortality and morbidity rates. Although the advantages of
antegrade flow could not be established in our series, reluctance to manipulate the dissected aorta for
canulation does not seem warranted.

Reported studies on DA cannulation in ATAAD surgery are relatively limited. In 2009, Kamiya et al.
showed comparable outcomes on 30-day mortality (14% vs. 23%, P = 0.07) and stroke (4.9% vs. 4.5%,
[24]
P = 0.86) between DA and FA cannulation . More recently, Jormalainen et al. completely shifted to DA
cannulation in ATAAD patients after they observed similar hospital mortality (13.8% vs. 13.5%, P = 0.962)
[25]
and stroke rates (22.3% vs. 25%, P = 0.617). Reece et al. even showed DA cannulation has significantly
lower perioperative myocardial infarction (P < 0.01) and 30-day mortality (P < 0.05) than FA and RAX
[26]
cannulation . Kreibich et al performed a similar comparison between DA, FA, and RAX cannulation ,
[27]
reporting no significant differences regarding in-hospital mortality and stroke, with significantly shorter
ECC and cross-clamp time for DA compared to FA cannulation (198 vs. 212 min and 125 vs. 148 min,
respectively).

Current guidelines advocate cannulation, providing antegrade flow, especially RAX cannulation for stable
patients [7,17] . A meta-analysis comprising 715 patients showed a significant reduction in mortality (P < 0.01)
and stroke (P < 0.01) for RAX cannulation compared to FA cannulation . In this study, however,
[14]
malperfusion (a feared complication of FA cannulation) did not differ significantly between both groups
(RAX 5.7% vs. FA 6.6%, P = 0.67). Another systematic review showed DA cannulation has lower mortality
and malperfusion rates compared to FA cannulation, although the stroke rate is higher than that of RAX
cannulation . Sabashnikov, on the other hand, showed no significant differences in neurological outcomes
[19]
when comparing DA cannulation to RAX in their study with 235 patients . Recently, Ramaprabhu et al.
[28]
showed no significant differences between DA and RAX cannulation on mortality, stroke, and overall
[29]
survival (P = 0.863, P = 0.463, and P = 0.629, respectively) . In both the German Registry for Acute Aortic
Dissection Type A (GERAADA) database and the Nordic Consortium for Acute Type A Aortic Dissection
(NORCAAD) database, cannulation site did not affect early mortality (15.1% vs. 18.8%, P > 0.1 and
[4,8]
19.2% vs. 18.9%, respectively) . Although non-significant, more AKI was observed in direct aortic