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

1.

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 Nov. 16];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.