Comparison of Outcomes between Axillary and Femoral Artery Cannulation for Type A Aortic Dissection Surgery

Special Article - Aortic Dissection Surgery

Austin J Surg. 2019; 6(7): 1176.

Comparison of Outcomes between Axillary and Femoral Artery Cannulation for Type A Aortic Dissection Surgery

Lei W¹, Hong WZ², Xin C¹* and Wang LM¹

¹Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, China

²Department of Anesthesiology Nanjing First Hospital, Nanjing Medical University, China

*Corresponding author: Chen Xin, Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China

Received: March 03, 2019; Accepted: March 26, 2019; Published: April 02, 2019


Objective: To compare the application and outcome of femoral and axillary arterial cannulation in adult type A aortic dissection surgery.

Methods: 108 patients underwent type A aortic dissection surgery were divided into as the femoral artery cannulation group (n=53) and the axillary artery cannulation group (n=55) according to intraoperative arterial cannulation. General condition, cardiopulmonary bypass time and postoperative major complication retrospectively reviewed and compared between. Multivariate logistic analysis models were used to identify the independent predictors of risk factors of death.

Result: Operative mortality was not influenced by cannulation site (18.1% for axillary cannulation vs. 15.1% for femoral cannulation. Multivariate logistic analysis showed that age (age=70 years) and extracorporeal cardiopulmonary bypass time (CPB=250 min) were independent risk factors for surgical death. Early stoke, renal injury and cognitive dysfunction were comparable between the groups.

Conclusion: The outcomes of femoral versus axillary arterial cannulation in patients with acute type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles. In addition, pre-operative hemodynamic instability, CPB time and body mass index (BMI=30kg/m2) are independent risk factors of operative death.


Acute Aortic Dissection type A (AADA) is a life threatening medical condition with a high mortality rate and more postoperative complications of cardiovascular emergency, surgical treatment is the only way to save the patients. Sun’s procedure (total arch replacement using 4-branched graft with implantation of a special stented graft in the descending aorta) is widely used because of its good surgical results, and arterial cannulation is the first successful operation of the implementation [1,2]. The femoral artery and axillary are commonly used for artery cannulation. In recent years, with the improvement of surgical techniques, surgical mortality and postoperative complications of patients were gradually decreased. Meanwhile, the location of the arterial cannulation is changed from the femoral artery to the axillary artery [3]. Although some heart centers still choose femoral artery as a choice of arterial cannulation site for aortic dissection, studies have confirmed that reverse blood flow in the femoral cannulation leads to increased risk of retrograde embolization, dissection in patients with atherosclerosis, and of brain or organ mal-perfusion in those operated for type A acute aortic dissection [4]. Benedetto [5] through the meta-analysis found that central cannulation surgery may be better than the peripheral cannulation in the short term, but the latest guideline has not yet been provided for the use of the axillary artery as a cannulation site during dissection surgery because the data is from non-random experiments, and is thus jeopardized by several sources of bias [6]. The aim of this study was to investigate whether the axillary artery cannulation was superior to the femoral artery in patients with type A aortic dissection.

Patients and Methods

A total of 108 patients underwent aortic surgery for type A aortic dissection between January 2015 and June 2017. Patients who had history of cerebrovascular disease, severe carotid artery stenosis and combined other organ complications (liver and kidney dysfunction) were excluded from the study in order to reduce undesired bias. Among them 55 cases were axillary artery cannulation and 53 cases were femoral artery cannulation. This study was approved by the Institutional Review Board at Nanjing Medical University in compliance with Health Insurance Portability and Accountability Act regulations and the Declaration of Helsinki. The Institutional Review Board waived the need for individual patient consent.

Surgical technique

Anesthetic technique and monitoring was the same as that used for other cardiac surgical procedures, except for the placement of bilateral radial arterial lines. Invasive monitoring included the use of a pulmonary artery catheter and a left radial-femoral arterial line to allow measurement of systemic perfusion pressures during CPB. A Foley catheter with a temperature probe was inserted to measure bladder temperature. This was used as our indicator of core body temperature. Electroencephalogram monitoring was routinely performed in all cases. Intraoperative transesophageal echocardiography was used in all patients. The HL-20 (Maquet, Hirrlingen, Germany) was used for CPB. The extracorporeal circuit was primed using 200-220 ml of a solution that included donor red blood cells (to maintain an hematocrit of at least 30%), 20% albumin, sodium bicarbonate, mannitol and heparin. CPB was performed with a flow of 2.0-2.8 min with about 40 min of prior cooling to a nasopharyngeal temperature of 25°C, with a temperature gradient not exceeding 10°C. The blood gases were maintained in an alpha-stat strategy, with a target pCO2 of 40mmHg. The goal core body temperature was variable and depended upon several factors, including age, preoperative renal function, aortic pathology and the complexity of the planned aortic arch reconstruction.

Deep Hypothermic Circulatory Arrest (DHCA) was carried out when the nasopharyngeal temperature reached the goal temperature. Selective Ante Grade Cerebral Perfusion (SACP), with a flow of 5-8, was performed through the right axillary artery or femoral artery. The left common carotid artery, the left subclavian artery and the descending aorta were clamped after the start of SACP. Depending on the individual anatomy, aortic arch reconstruction used procedures such as ascending aorta replacement, right arch replacement and Bentall and Sun’s procedure.

Statistical analysis

SPSS20.0 software was used for statistical analysis. Comparison between the two groups we used independent samples t test, the comparison between multiple groups using variance analysis. Count data in the rate or composition ratio, the comparison between groups using chi-square test. For mortality risk factor distribution a univariate analysis was performed. All significant parameters from the univariate analysis were included in a multivariate logistic regression. P<0.05 for the difference was statistically significant.


Preoperative demographics of subjects

One hundred and eight patients comprised the statistical analysis population. The axillary artery group had 55 patients with 32 males while 53 patients with 29 males in femoral artery group. The median age was similar in both groups: 54.8±9.9years in axillary artery group and 53.8±7.9 years in femoral artery group. Medical histories included hypertension, Diabetes Mellitus (DM), preoperative diagnosis, body mass index, smoking and high cholesterol. There was no difference in the above characteristics of the patients in the two groups. Pre-OP hemodynamic instability was more common in the femoral artery group than the axillary artery group, which may be due to sudden cardiovascular events (malignant arrhythmia, acute left heart failure) needing emergent surgery and femoral artery cannulation for CPB is faster than axillary artery cannulation (Table 1).