Original article: cardiovascularDoes the Arterial Cannulation Site for Circulatory Arrest Influence Stroke Risk?
Section snippets
Patients and Methods
Between January 1993 and May 2003, 1,352 operations for complex cardiac and cardioaortic problems were performed with circulatory arrest on 1,318 patients (32 had 2 operations, and 1 had 3). Excluded from the study were patients who had coronary artery bypass grafting or aortic valve replacement alone. These operations were identified from the Cardiovascular Information Registry, an ongoing registry of clinical and outcome data that is updated concurrently with patient care. Data in this
Cannulation Sites
A total of 1,336 operations involved the use of a single arterial inflow cannulation site, and these formed the basis for our comparisons. (In 16 operations, 2 sites were usedâin 12, aortic and femoral; in 2, femoral and subclavian; in 1, both subclavians; and in 1, innominate and aortic. These patients were not included in the comparative analyses.) Single cannulation sites were aorta (n = 471), femoral (n = 374), axillary (n = 258; 166 with side graft), subclavian (n = 208; 133 with side
Operations and Other Support Techniques
Two hundred seventy-two patients underwent emergency operation, 432 underwent reoperation (71 had previously had placed ascending aortic/arch grafts), and 439 had operations for aortic dissection, of whom 223 underwent emergency operation for acute dissection; 711 had aortic aneurysms (Table 1). Circulatory arrest was used because of ascending or aortic arch arteriosclerosis or atheroma in 301 patients and calcification in 278 (total 450). Aortic valve procedures were performed in 770
Outcome
The 2 primary measures of outcome were stroke and mortality. Stroke was defined as a physician-diagnosed new postoperative neurologic deficit lasting more than 72 hours, generally confirmed by computed tomography of the head, and considered to be a cerebral vascular accident. Mortality was defined as in-hospital death from any cause. In addition, other postoperative complications were tabulated, including bleeding, defined as a return to the operating room for excessive postoperative bleeding
General
The Ï2 test was used for comparing categorical variables when the smallest number of individuals in a category was greater than 5, and Fisher's exact test was used otherwise. Continuous variables were compared by using the t test or Wilcoxon's rank-sum test if distribution of the variable was skewed.
Strategy
The primary analyses were comparisons of hospital outcome after operations in which Ax plus SG had been used versus those of various direct cannulation strategies. Because patient, pathologic, and
Stroke
Stroke occurred in 81 of the 1,336 patients (6.1%; CL, 5.4% to 6.8%). Among 299 patients who had Ax plus SG, stroke occurred in 12 (4.0%), versus 69 (6.7%) among 1,037 who had direct cannulation (Table 3, Table 4).
Although the occurrence of stroke was higher by each method of direct cannulation, unadjusted and propensity-matched comparisons of individual techniques indicated that the differences could possibly (p = 0.08) or probably (p = 0.2) be due to chance. The propensity-matched comparison
Comparison of Cannulation Strategies
The arterial inflow site for cardiopulmonary bypass grafting has varied over the last 5 decades. Initially, femoral or subclavian arteries were used, but distal ascending aortic inflow then became the preferred site. Subsequently, direct femoral artery cannulation was advocated for most ascending aortic and aortic arch procedures and also for some reoperations [16]. This approach, however, was associated with a greater risk of stroke in some patient groups, particularly those with concurrent
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