Arterial Cannulation and Cerebral Perfusion Strategies for Acute Type A Dissection in US
Friday, January 24, 2025
12:41pm – 12:48pm PT
Location: Exhibit Hall Theater 1
M. Koprivanac1, N. D. Desai2, F. Stembal3, R. Habib4, S. Chang5, L. Bonnell6, V. Lara-Erazo7, P. Vargo8, K. M. Lawrence2, X. Lou9, J. Bavaria10, F. Bakaeen11, W. Y. Szeto2, E. E.. Roselli12, L. Svensson12 1Cleveland Clinic Foundation, Hunting Valley, Ohio 2University of Pennsylvania, Philadelphia, Pennsylvania 3Cleveland Clinic, Zagreb, Grad Zagreb 4The Society of Thoracic Surgeons, CHICAGO, Illinois 5STS, Philadelphia, Pennsylvania 6The Society of Thoracic Surgeons, Philadelphia, Pennsylvania 7CCF, Cleveland, Ohio 8Cleveland clinic, Bay Village, Ohio 9Cleveland Clinic, Beachwood, Ohio 10Hospital of the University of Pennsylvania, Dept. of Cardiovascular S, Philadelphia, Pennsylvania 11The Cleveland Clinic Foundation, Cleveland, Ohio 12Cleveland Clinic, Cleveland, Ohio
Disclosure(s):
Marijan Koprivanac, MD, MS: No financial relationships to disclose
Purpose: We aimed to determine national trends and potential impact on outcomes of arterial cannulation and cerebral perfusion strategies during Acute Type A Dissection surgery. We, therefore, analyzed the national-scale data in the STS Adult Cardiac Surgery Database (ACSD) to assess the association of these strategies with postoperative mortality and stroke. Methods: Patients who underwent surgery for acute type A dissection (ATAAD) in the United States were identified from the STS ACSD between July 2011 and December 2023 (N=47,936). Mean age was 60 years, 34% were female and median BMI was 29 (IQR, 25-34). All arterial cannulation approaches were studied including i) single or isolated axillary, femoral, aortic, or innominate artery access, and ii) multiple cannulations (≥2). Cerebral/brain perfusion (CP) was categorized to: antegrade (ACP), retrograde (RCP), both, or none. Risk-adjusted operative mortality and stroke analysis was performed on the July 2017-2023 sub-cohort to maximize granularity of the aorta disease and repair data. The analyzed cases (N = 23,551) involved the ascending aorta or arch with or without aortic root involvement. Multivariable logistic regression models adjusted for preoperative risk factors, aorta disease (malperfusion), intraoperative variables (hypothermia, AC/CP strategy, aortic root and open arch procedures-distal site and extension), and hospital volume category. Results: Over the last 12 years, femoral arterial cannulation usage dropped from 36.8% to 19%, while direct aortic and axillary cannulation increased from 18.6% to 31.7%, and 25.8% to 29.2%, respectively. [Figure 1A] Use of RCP was similar (21.9% to 21.3%), while ACP increased from 21.9% to 51.6%. ATAAD repair without CP decreased from 52% to 23.3%. [Figure 1B]. Axillary cannulation with ACP was the most frequent protection strategy (Axillary-ACP: 24.4%), had the lowest mortality (15.4%), and was used as reference. Malperfusion was common (25.1%) while 5.8% had neuro deficit on presentation. Operative mortality and stroke rates were 18.3% and 14.0%, respectively. Compared to Axillary-ACP strategy, mortality was similar with aortic cannulation-ACP strategy adjusted for preoperative/intraoperative risk factors (aOR=1.12; 95% CI=0.97-1.30; p=0.12; Figure 1C), but worse when further adjusted for hospital volume (aOR=1.17; 95% CI=1.01-1.36; p=0.03; Figure 1D). Femoral-ACP or Femoral-NoCP approaches had worse mortality (p < 0.001). Femoral with RCP after adjustment for preoperative/intraoperative risk factors had worse mortality (p=0.03) but after further adjustment for volume there was no difference (p=0.19). Perioperative stroke incidence was higher in femoral cannulation with all CP strategies (p < 0.05). Direct aortic cannulation had higher stroke rate with ACP while with RCP there was no difference. Conclusion: There have been recent positive trends in ATAAD repair. To optimize outcomes, use of brain perfusion is preferred over none, and cannulation that provides proximal to distal flow is preferred over femoral. Direct aortic provides comparable results to axillary cannulation but demands surgeon expertise and skilled handling of direct ACP.
Identify the source of the funding for this research project: STS sponsored study