Subclavian artery cannulation provides superior outcomes in patients with  acute type-A dissection: long-term results of 290 consecutive patients

Ulrich PF Schurr; Maximilian Y Emmert; Denis Berdajs; Oliver Reuthebuch; Burkhardt Seifert; Omer Dzemali; Michele Genoni

doi:10.4414/smw.2013.13858

Original article

Vol. 143 No. 4344 (2013)

Subclavian artery cannulation provides superior outcomes in patients with acute type-A dissection: long-term results of 290 consecutive patients

Ulrich PF Schurr
Maximilian Y Emmert
Denis Berdajs
Oliver Reuthebuch
Burkhardt Seifert
Omer Dzemali
Michele Genoni

DOI: https://doi.org/10.4414/smw.2013.13858
Cite this as:: Swiss Med Wkly. 2013;143:w13858
Published: 20.10.2013

Summary

OBJECTIVES: The short-term results of subclavian artery cannulation (SC) for acute type-A dissection repair have been reported to be superior in regard to mortality and neurological outcomes when compared to femoral cannulation (FC). This study evaluates the long-term results of subclavian artery cannulation versus femoral cannulation for repair of acute type-A dissection with particular regard to neurological deficits, mortality and the need for re-operations.

METHODS: From 1992–2005, 346 patients underwent surgical repair of acute type-A dissection of which 290 patients survived the operation. SC was performed in 114 patients and FC in 176 patients. Follow-up (FU) was completed in 89.5% (n = 259) and the medium FU-period was 42 months (SC) and 69 months (FC). Endpoints were persistence of neurological-deficits, mortality, major complications and necessity for re-operations.

RESULTS: Overall survival and disease-free survival at 5 years were significantly higher in the SC group (83% vs. 71%; p = 0.022 and 74% vs. 61%; p = 0.044). Freedom of re-operation also appeared to be higher in the SC group (89% vs. 79%; p = 0.125). During the follow-up period, 28 patients (11/114 vs. 17/176; p = 0.58) suffered from neurological deficits of which 16 patients had permanent neurological-deficits at the 5 year follow-up. Of these patients, significantly more belonged to the FC group indicating an improved neurological-outcome for the SC group (3/11 vs. 13/17; p = 0.019).

CONCLUSIONS: This study demonstrates excellent long-term outcomes after emergency surgery for acute type-A dissection. Subclavian artery perfusion represents an excellent approach to repair acute type-A dissection. Beside a significantly reduced long-term mortality, this technique provides an improved neurological outcome and a higher disease-free survival-rate.

References

Bachet J, Goudot B, Dreyfus GD, Brodaty D, Dubois C, Delentdecker P, et al. Surgery for acute type A aortic dissection: the Hopital Foch experience (1977–1998). Ann Thorac Surg. 1999;67:2006–9; discussion 2014–2009.
Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation. 1990;82:IV24–38.
Chiappini B, Schepens M, Tan E, Dell’ Amore A, Morshuis W, Dossche K, et al. Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J. 2005;26:180–6.
Haverich A, Miller DC, Scott WC, Mitchell RS, Oyer PE, Stinson EB, et al. Acute and chronic aortic dissections – determinants of long-term outcome for operative survivors. Circulation. 1985;72:II22–34.
Lai DT, Robbins RC, Mitchell RS, Moore KA, Oyer PE, Shumway NE, et al. Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection? Circulation. 2002;106:I218–28.
Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg. 2000;119:946–62.
Reuthebuch O, Schurr U, Hellermann J, Pretre R, Kunzli A, Lachat M, et al. Advantages of subclavian artery perfusion for repair of acute type A dissection. Eur J Cardiothorac Surg. 2004;26:592–8.
Glower DD, Speier RH, White WD, Smith LR, Rankin JS, Wolfe WG. Management and long-term outcome of aortic dissection. Ann Surg. 1991;214:31–41.
Tsai TT, Fattori R, Trimarchi S, Isselbacher E, Myrmel T, Evangelista A, et al. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation. 2006;114:2226–31.
Kazui T, Kimura N, Yamada O, Komatsu S. Surgical outcome of aortic arch aneurysms using selective cerebral perfusion. Ann Thorac Surg. 1994;57:904–11.
Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg. 1995;109:885–890; discussion 890–881.
Ehrlich MP, Hagl C, McCullough JN, Zhang N, Shiang H, Bodian C, et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thorac Cardiovasc Surg. 2001;122:331–8.
Ehrlich MP, Fang WC, Grabenwoger M, Kocher A, Ankersmit J, Laufer G, et al. Impact of retrograde cerebral perfusion on aortic arch aneurysm repair. J Thorac Cardiovasc Surg. 1999;118:1026–32.
Griepp RB. Cerebral protection during aortic arch surgery. J Thorac Cardiovasc Surg. 2001;121:425–7.
Hagl C, Ergin MA, Galla JD, Lansman SL, McCullough JN, Spielvogel D, et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg. 2001;121:1107–21.
Van Arsdell GS, David TE, Butany J. Autopsies in acute type A aortic dissection. Surgical implications. Circulation. 1998;98:II299–302; discussion II302–294.
Pugliese P, Pessotto R, Santini F, Montalbano G, Luciani GB, Mazzucco A. Risk of late reoperations in patients with acute type A aortic dissection: impact of a more radical surgical approach. Eur J Cardiothorac Surg. 1998;13:576–80; discussion 580–571.
Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G, et al. Surgical management of aortic dissection during a 30-year period. Circulation. 1995;92:II113–121.
Niederhauser U, Kunzli A, Seifert B, Schmidli J, Lachat M, Zund G, et al. Conservative treatment of the aortic root in acute type A dissection. Eur J Cardiothorac Surg. 1999;15:557–63.
von Segesser LK, Lorenzetti E, Lachat M, Niederhauser U, Schonbeck M, Vogt PR, et al. Aortic valve preservation in acute type A dissection: is it sound? J Thorac Cardiovasc Surg. 1996;111:381–90; discussion 390–381.

How to Cite

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Schurr UP, Emmert M, Berdajs D, Reuthebuch O, Seifert B, Dzemali O, Genoni M. Subclavian artery cannulation provides superior outcomes in patients with acute type-A dissection: long-term results of 290 consecutive patients. Swiss Med Wkly [Internet]. 2013 Oct. 20 [cited 2024 Apr. 24];143(4344):w13858. Available from: https://smw.ch/index.php/smw/article/view/1769

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[1] Bachet J, Goudot B, Dreyfus GD, Brodaty D, Dubois C, Delentdecker P, et al. Surgery for acute type A aortic dissection: the Hopital Foch experience (1977–1998). Ann Thorac Surg. 1999;67:2006–9; discussion 2014–2009.

[2] Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation. 1990;82:IV24–38.

[3] Chiappini B, Schepens M, Tan E, Dell’ Amore A, Morshuis W, Dossche K, et al. Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J. 2005;26:180–6.

[4] Haverich A, Miller DC, Scott WC, Mitchell RS, Oyer PE, Stinson EB, et al. Acute and chronic aortic dissections – determinants of long-term outcome for operative survivors. Circulation. 1985;72:II22–34.

[5] Lai DT, Robbins RC, Mitchell RS, Moore KA, Oyer PE, Shumway NE, et al. Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection? Circulation. 2002;106:I218–28.

[6] Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg. 2000;119:946–62.

[7] Reuthebuch O, Schurr U, Hellermann J, Pretre R, Kunzli A, Lachat M, et al. Advantages of subclavian artery perfusion for repair of acute type A dissection. Eur J Cardiothorac Surg. 2004;26:592–8.

[8] Glower DD, Speier RH, White WD, Smith LR, Rankin JS, Wolfe WG. Management and long-term outcome of aortic dissection. Ann Surg. 1991;214:31–41.

[9] Tsai TT, Fattori R, Trimarchi S, Isselbacher E, Myrmel T, Evangelista A, et al. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation. 2006;114:2226–31.

[10] Kazui T, Kimura N, Yamada O, Komatsu S. Surgical outcome of aortic arch aneurysms using selective cerebral perfusion. Ann Thorac Surg. 1994;57:904–11.

[11] Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg. 1995;109:885–890; discussion 890–881.

[12] Ehrlich MP, Hagl C, McCullough JN, Zhang N, Shiang H, Bodian C, et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thorac Cardiovasc Surg. 2001;122:331–8.

[13] Ehrlich MP, Fang WC, Grabenwoger M, Kocher A, Ankersmit J, Laufer G, et al. Impact of retrograde cerebral perfusion on aortic arch aneurysm repair. J Thorac Cardiovasc Surg. 1999;118:1026–32.

[14] Griepp RB. Cerebral protection during aortic arch surgery. J Thorac Cardiovasc Surg. 2001;121:425–7.

[15] Hagl C, Ergin MA, Galla JD, Lansman SL, McCullough JN, Spielvogel D, et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg. 2001;121:1107–21.

[16] Van Arsdell GS, David TE, Butany J. Autopsies in acute type A aortic dissection. Surgical implications. Circulation. 1998;98:II299–302; discussion II302–294.

[17] Pugliese P, Pessotto R, Santini F, Montalbano G, Luciani GB, Mazzucco A. Risk of late reoperations in patients with acute type A aortic dissection: impact of a more radical surgical approach. Eur J Cardiothorac Surg. 1998;13:576–80; discussion 580–571.

[18] Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G, et al. Surgical management of aortic dissection during a 30-year period. Circulation. 1995;92:II113–121.

[19] Niederhauser U, Kunzli A, Seifert B, Schmidli J, Lachat M, Zund G, et al. Conservative treatment of the aortic root in acute type A dissection. Eur J Cardiothorac Surg. 1999;15:557–63.

[20] von Segesser LK, Lorenzetti E, Lachat M, Niederhauser U, Schonbeck M, Vogt PR, et al. Aortic valve preservation in acute type A dissection: is it sound? J Thorac Cardiovasc Surg. 1996;111:381–90; discussion 390–381.