Original article: cardiovascular
Does the Arterial Cannulation Site for Circulatory Arrest Influence Stroke Risk?

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.
https://doi.org/10.1016/j.athoracsur.2004.04.063Get rights and content

Abstract

Background

We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest.

Methods

Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression.

Results

Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs).

Conclusions

Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

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 used—in 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 χ2 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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