Mortality and Neurological Complications after Direct True Lumen Cannulation in Patients with Acute Stanford Type A Dissection

Introduction: Direct true lumen cannulation (DTLC) in patients with acute Stanford type A dissection (AAD) provides antegrade perfusion, does not require separate surgical preparation of an additional arterial cannulation site, and allows fast establishment of CPB.

Methods: We identified all patients who underwent surgical repair of AAD using DTLC within a period of 7 years and retrospectively reviewed the cases thus identified for occurrence of neurological complications.

Results: DTLC was used in 211 patients (65.9% male, 64.6 ± 13.3 years) with AAD. The supra-aortic vessels and the aortic arch were involved in the dissection in 80% and 95%, respectively. Preoperative cerebral and spinal malperfusion were present in 30 (14%) and 15 (7%) patients. 12 (6%) underwent aortic repair after cardiopulmonary resuscitation. Preoperative neurological deficits consisting of hemiparesis or non-responsiveness were present in 12 (6%), and an unclear neurological status was documented in 5 (2.4%). The ascending aorta was replaced in all cases, with additional hemiarch or arch replacement in 45 (21.3%) and 12 (5.7%) patients, respectively. A valved conduit was used in 2 (1%), and aortic valve replacement took place in 8 (3.8%). David and Yacoub procedures were performed in 1 case (0.5%) each, and 15 (7.1%) underwent concomitant aortocoronary bypass grafting. 30-day survival was 84.91%. Postoperative neurological examination showed hemiparesis in 24 (11.4%), paraparesis in 7 (3.3%), aphasia in 4 (1.9%), and non-responsiveness in 16 (7.6%). Discussion Transection of the ascending aorta and cannulation of the true lumen take place during a short period of normothermic circulatory arrest after draining the greater part of the patient's blood volume into the venous reservoir. Performed by an experienced surgeon, the period of normothermic circulatory arrest can be limited to 1 - 2 minutes, followed by establishment of CPB and induction of hypothermia. Our series demonstrates that mortality and neurological complication rates of surgical treatment of AAD using DTLC do not exceed the rates found in literature for other cannulation methods.

Conclusion: DTLC in patients with AAD is not inferior to other cannulation methods in terms of mortality and neurological complication rates. It represents a straightforward and safe way to establish antegrade perfusion quickly and should therefore be preferred over other cannulation strategies.