Gen Thorac Cardiovasc Surg (2014) 62:271–272 DOI 10.1007/s11748-014-0382-1
EDITORIAL
Editorial comment for ‘Safety and efficacy of ascending aorta cannulation during repair of acute type A aortic dissection’ Kazuo Yamanaka
Received: 9 January 2014 / Published online: 8 March 2014 Ó The Japanese Association for Thoracic Surgery 2014
Keywords Acute type A aortic dissection Central cannulation Cannulation site
Editorial comment I read the article by Osumi et al. with great interest. The authors investigated the results of surgery on 52 patients with acute type A aortic dissection (AAAD). In this study, they discussed the central cannulation technique which had been accepted in several institutions in recent years. The central cannulation group showed shorter operation time, shorter cardiopulmonary bypass (CPB) time and lower mortality rate than the peripheral group. They concluded that the central cannulation technique for AAAD was more rapid and safer compared with the peripheral cannulation technique. Lijoi has reported, for the first time, this technique in 1998 [1]. Subsequently, Minatoya [2], Noiseuxa [3] and Yamada [4] have reported this technique. In addition, Jakob [5] has introduced the aggressive direct cannulation technique in 2007. Although there are a wide variety of central cannulation techniques, most institutions use the Seldinger technique under ultrasound guidance. Our institution [6, 7] also uses the similar technique to that reported by the authors.
This comment refers to the article available at doi:10.1007/s11748013-0355-9. K. Yamanaka (&) Division of Cardiovascular Surgery, Tenri Hospital, 200 Mishimacho, Tenri, Nara 632-8552, Japan e-mail: [email protected]
I can understand that the mean operation time and the interval time between the start of operation and the start of CPB were shorter, but I wonder about lower mortality and morbidity in the central cannulation approach [8, 9]. I think that the patient selection and the small number of patient cohort may have led to these results. The best site of cannulation for AAAD still remains controversial. We need further large-scale multicenter randomized control trials. While we have utilized the central cannulation technique in many cases since 1999, we have alternatively selected axillary artery (AXA), femoral artery (FA) and apex of left ventricle (LV apex) on a case by case basis. We have the central cannulation approach for all cases of AAAD since 2007. If impossible, we converted other sites (e.g. AXA, FA and LV apex). One hundred thirty consecutive patients underwent prosthetic graft replacement of the ascending aorta or aortic arch for AAAD between 2007 and 2012. The mean age of patients with AAAD was 68 years. The male/female proportion was approximately even. The success rate of the central cannulation approach was 94 % (122/130). We could not establish CPB by the central cannulation approach in eight patients. The alternative cannulation sites were FA (2 cases), AXA (3 cases) and LV apex (3 cases). We classified failed cases into four groups based on the reasons: (1) Inadequate perfusion flow (2 cases), (2) Collapse of the true lumen (2 cases), (3) Collapse of the ascending aorta due to massive bleeding or cardiac arrest (3 cases) and (4) Complete disjunction of the aortic intima (1 case). I did not know the cause of inadequate perfusion flow in details. We suppose that the cannula may have moved to the false lumen. Collapse of the true lumen is not rare in AAAD. Although we can perform central cannuation successfully even in the presence of collapse of the true lumen, it was impossible in two cases. We have done
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Gen Thorac Cardiovasc Surg (2014) 62:271–272
cannulation through LV apex in the case of collapse of the ascending aorta. It was absolutely impossible to conduct cannulation into the true lumen in case of complete disjunction of aortic intima. In case of uncontrollable bleeding (ex. rupture of Valsalva sinus), we may adopt the direct cannulation technique proposed by Jakob [5], namely incision of the false and true lumens and visual open cannulation under aortic cross-clamping. I have used this technique in one case. This technique appears to be a good other option. In our perioperative data, the time from skin incision to extra cardiac circulation (ECC) (27 ± 11 min), the ventilation time (88 ± 92 h), ICU stay (9.9 ± 8.2 days), hospital stay (34.5 days) and the hospital mortality rate were similar to those in this paper. Fortunately, there were no complications related to the central cannulation. Although it is difficult to evidence the superiority of the central cannulation approach for AAAD in present, there are possibly some advantages: (1) Ease and safe technique, (2) Prompt induction of CPB, (3) Higher flow and lower pressure on ECC, (4) Avoidance of retrograde flow in the downstream aorta. Conflict of interest
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None of declare.
References 1. Lijoi A, Scarano F, Dottori V, et al. Stanford type A aortic dissection. A new surgical approach. Tex Heart Inst J. 1998;25: 65–7. 2. Minatoya K, Karck M, Szpakowski E, et al. Ascending aortic cannulation for Stanford type A acute aortic dissection: another option. J Thorac Cardiovasc Surg. 2003;125:952–3. 3. Noiseux N, Coutureb P, Sheridanb P, et al. Aortic cannulation for type A dissection: guidance by transesophageal echocardiography. Interact Cardiovasc Thorac Surg. 2003;2:178–80. 4. Yamada T, Yamazato A. Central cannulation for type A acute aortic dissection. Interact Cardiovasc Thorac Surg. 2003;2:175–7. 5. Jacob H, Tsagakis K, Szabo A, et al. Rapid and safe direct cannulation of the true lumen of ascending aorta in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2007;134:244–5. 6. Yamanaka K, Hori Y, Ikarashi J, et al. Durability of aortic valve preservation with root reconstruction for acute type A aortic dissection. Eur J Cardiothorac Surg. 2012;41:e32–6. 7. Yamanaka K. Strategy for aute type A aortic dissection. Circulation Up-to-Date. 2010;5:537–43. 8. Reece TB, Tribble CG, Smith RL, et al. Central cannulation is safe in acute aortic dissection repair. J Thorac Cardiovasc Surg. 2007;133:428–34. 9. Kamiya H, Kallenbach K, Halmer D, et al. Comparison of ascending aorta versus femoral artery cannulation for acute aortic dissection type A. Circulation. 2009;120(11 Suppl):S282–6.
EDITORIAL
Editorial comment for ‘Safety and efficacy of ascending aorta cannulation during repair of acute type A aortic dissection’ Kazuo Yamanaka
Received: 9 January 2014 / Published online: 8 March 2014 Ó The Japanese Association for Thoracic Surgery 2014
Keywords Acute type A aortic dissection Central cannulation Cannulation site
Editorial comment I read the article by Osumi et al. with great interest. The authors investigated the results of surgery on 52 patients with acute type A aortic dissection (AAAD). In this study, they discussed the central cannulation technique which had been accepted in several institutions in recent years. The central cannulation group showed shorter operation time, shorter cardiopulmonary bypass (CPB) time and lower mortality rate than the peripheral group. They concluded that the central cannulation technique for AAAD was more rapid and safer compared with the peripheral cannulation technique. Lijoi has reported, for the first time, this technique in 1998 [1]. Subsequently, Minatoya [2], Noiseuxa [3] and Yamada [4] have reported this technique. In addition, Jakob [5] has introduced the aggressive direct cannulation technique in 2007. Although there are a wide variety of central cannulation techniques, most institutions use the Seldinger technique under ultrasound guidance. Our institution [6, 7] also uses the similar technique to that reported by the authors.
This comment refers to the article available at doi:10.1007/s11748013-0355-9. K. Yamanaka (&) Division of Cardiovascular Surgery, Tenri Hospital, 200 Mishimacho, Tenri, Nara 632-8552, Japan e-mail: [email protected]
I can understand that the mean operation time and the interval time between the start of operation and the start of CPB were shorter, but I wonder about lower mortality and morbidity in the central cannulation approach [8, 9]. I think that the patient selection and the small number of patient cohort may have led to these results. The best site of cannulation for AAAD still remains controversial. We need further large-scale multicenter randomized control trials. While we have utilized the central cannulation technique in many cases since 1999, we have alternatively selected axillary artery (AXA), femoral artery (FA) and apex of left ventricle (LV apex) on a case by case basis. We have the central cannulation approach for all cases of AAAD since 2007. If impossible, we converted other sites (e.g. AXA, FA and LV apex). One hundred thirty consecutive patients underwent prosthetic graft replacement of the ascending aorta or aortic arch for AAAD between 2007 and 2012. The mean age of patients with AAAD was 68 years. The male/female proportion was approximately even. The success rate of the central cannulation approach was 94 % (122/130). We could not establish CPB by the central cannulation approach in eight patients. The alternative cannulation sites were FA (2 cases), AXA (3 cases) and LV apex (3 cases). We classified failed cases into four groups based on the reasons: (1) Inadequate perfusion flow (2 cases), (2) Collapse of the true lumen (2 cases), (3) Collapse of the ascending aorta due to massive bleeding or cardiac arrest (3 cases) and (4) Complete disjunction of the aortic intima (1 case). I did not know the cause of inadequate perfusion flow in details. We suppose that the cannula may have moved to the false lumen. Collapse of the true lumen is not rare in AAAD. Although we can perform central cannuation successfully even in the presence of collapse of the true lumen, it was impossible in two cases. We have done
123
272
Gen Thorac Cardiovasc Surg (2014) 62:271–272
cannulation through LV apex in the case of collapse of the ascending aorta. It was absolutely impossible to conduct cannulation into the true lumen in case of complete disjunction of aortic intima. In case of uncontrollable bleeding (ex. rupture of Valsalva sinus), we may adopt the direct cannulation technique proposed by Jakob [5], namely incision of the false and true lumens and visual open cannulation under aortic cross-clamping. I have used this technique in one case. This technique appears to be a good other option. In our perioperative data, the time from skin incision to extra cardiac circulation (ECC) (27 ± 11 min), the ventilation time (88 ± 92 h), ICU stay (9.9 ± 8.2 days), hospital stay (34.5 days) and the hospital mortality rate were similar to those in this paper. Fortunately, there were no complications related to the central cannulation. Although it is difficult to evidence the superiority of the central cannulation approach for AAAD in present, there are possibly some advantages: (1) Ease and safe technique, (2) Prompt induction of CPB, (3) Higher flow and lower pressure on ECC, (4) Avoidance of retrograde flow in the downstream aorta. Conflict of interest
123
None of declare.
References 1. Lijoi A, Scarano F, Dottori V, et al. Stanford type A aortic dissection. A new surgical approach. Tex Heart Inst J. 1998;25: 65–7. 2. Minatoya K, Karck M, Szpakowski E, et al. Ascending aortic cannulation for Stanford type A acute aortic dissection: another option. J Thorac Cardiovasc Surg. 2003;125:952–3. 3. Noiseux N, Coutureb P, Sheridanb P, et al. Aortic cannulation for type A dissection: guidance by transesophageal echocardiography. Interact Cardiovasc Thorac Surg. 2003;2:178–80. 4. Yamada T, Yamazato A. Central cannulation for type A acute aortic dissection. Interact Cardiovasc Thorac Surg. 2003;2:175–7. 5. Jacob H, Tsagakis K, Szabo A, et al. Rapid and safe direct cannulation of the true lumen of ascending aorta in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2007;134:244–5. 6. Yamanaka K, Hori Y, Ikarashi J, et al. Durability of aortic valve preservation with root reconstruction for acute type A aortic dissection. Eur J Cardiothorac Surg. 2012;41:e32–6. 7. Yamanaka K. Strategy for aute type A aortic dissection. Circulation Up-to-Date. 2010;5:537–43. 8. Reece TB, Tribble CG, Smith RL, et al. Central cannulation is safe in acute aortic dissection repair. J Thorac Cardiovasc Surg. 2007;133:428–34. 9. Kamiya H, Kallenbach K, Halmer D, et al. Comparison of ascending aorta versus femoral artery cannulation for acute aortic dissection type A. Circulation. 2009;120(11 Suppl):S282–6.
