Aortic and innominate cannulation produced similar observed neurologic and survival outcomes in a single-center study of redo aortic aneurysm surgery. Wu and colleagues compared direct aortic cannulation with innominate artery inflow after chest exposure, using propensity matching and regression to explore differences between selected patients. The results support both as feasible options in this setting, but the retrospective design and small innominate cohort cannot establish equivalence or prove that one approach is safer.
Study Population and the Clinical Question
The investigators reviewed 201 patients undergoing reoperative sternotomy for ascending aortic or arch aneurysm repair between April 2010 and December 2024. The comparison included 119 patients receiving direct aortic cannulation and 34 receiving innominate cannulation. Thirty-nine patients with axillary access and nine with other cannulation approaches were excluded.
Indications included degenerative aneurysms and aneurysmal enlargement of residual chronic dissection after previous type A repair. This was not a study of acute dissection requiring initial repair. Most included patients had previous surgery involving the aortic root, ascending aorta, or arch, although previous operations were heterogeneous.
The study primarily asks which central site can provide systemic arterial inflow for cardiopulmonary bypass (CPB) once the chest has been exposed. It does not answer whether high-risk patients should have peripheral bypass established before resternotomy.
How Aortic and Innominate Cannulation Were Used
Direct aortic inflow was established through the distal ascending aorta, proximal arch, or an existing aortic graft. Innominate access was usually obtained through a 10-mm Dacron side graft sewn to the artery; two patients underwent direct innominate cannulation without a conduit. The choice depended on exposure, adhesions, vessel quality, previous reconstruction, surgeon preference, and cerebral-protection plans.
The distinction between systemic inflow and selective cerebral perfusion is important. A patient classified in the aortic group could subsequently receive antegrade cerebral perfusion through the innominate artery. The group label therefore identifies the initial systemic CPB inflow strategy, not every arterial connection used during the operation.
Neurologic Outcomes and In-Hospital Mortality
Propensity-score matching produced 34 patients in each group. The authors matched clinical characteristics and extent of arch replacement, reducing some of the substantial differences present in the original cohorts.
| Outcome | Aortic cannulation | Innominate cannulation |
|---|---|---|
| Stroke, unmatched | 16/119 (13.4%) | 5/34 (14.7%) |
| Stroke, matched | 3/34 (8.8%) | 5/34 (14.7%) |
| Encephalopathy/delirium, matched | 4/34 (11.8%) | 4/34 (11.8%) |
| In-hospital death, unmatched | 9/119 (7.6%) | 2/34 (5.9%) |
| In-hospital death, matched | 1/34 (2.9%) | 2/34 (5.9%) |
In multivariable analysis, innominate rather than aortic cannulation had an adjusted odds ratio for stroke of 1.499, with a wide 95% confidence interval of 0.427–5.262 (P=.528). That interval allows substantial uncertainty in either direction. Failure to find a significant association is not proof that the true risks are identical.
More extensive arch replacement showed a borderline association with stroke (adjusted odds ratio 3.213; 95% CI 0.996–10.360; P=.051). This suggests that operative complexity deserves attention, but the estimate does not establish an independent causal effect.
Cerebral Perfusion and Operative Differences
Before matching, partial or total arch replacement was much more frequent in the aortic group, whereas innominate access was used more often for hemiarch procedures. Cerebral protection also differed: innominate patients predominantly received antegrade cerebral perfusion alone, while the aortic group included antegrade, retrograde, and combined approaches.
After matching, CPB and cross-clamp times were similar, but the innominate group had longer circulatory arrest and a lower nadir temperature. End-of-procedure left regional cerebral oxygen saturation was lower with innominate access (median 67% versus 70%; P=.021), although this isolated monitoring difference did not translate into a demonstrated difference in the measured clinical neurologic outcomes.
Fresh-frozen plasma exposure remained higher in the matched innominate group (median six versus 3.5 units; P=.009). Transfusion decisions were discretionary, and era, procedure, and perfusion differences complicate attributing this finding to the cannulation site itself.
Practice Changed During the Study Period
Time period is a major limitation: 86.6% of aortic cases occurred in 2019 or later, compared with only 14.7% of innominate cases. The authors describe a shift toward direct aortic cannulation alongside changes in temperature management and arch-reconstruction practice.
Consequently, differences in arrest duration, cooling, transfusion, or monitoring may reflect evolving institutional practice and surgeon experience as well as access choice. Propensity matching cannot reliably remove every difference associated with these changes over a 14-year period.
Long-Term Survival Requires Cautious Interpretation
The authors report ten-year survival estimates of 66.6% after aortic cannulation and 65.0% after innominate cannulation, with no statistically significant overall survival difference (log-rank P=.551). The displayed survival curves were truncated at six years when the numbers at risk became small.
Follow-up limitations and the predominance of later operations in the aortic group reduce confidence in comparisons at the longest time horizons. The survival analysis is reassuring observational experience, not evidence of long-term equivalence.
What This Means for Perfusion Teams
The practical implication is to plan systemic inflow and cerebral protection together while keeping them conceptually distinct. Vessel quality, prior graft location, available exposure, arch reconstruction, and the anticipated perfusion transitions all matter. A cannulation label alone does not describe the entire cerebral-protection strategy.
Two reentry injuries occurred in the aortic group and none in the innominate group, but the study was not designed to compare protective strategies before chest entry. Its conclusions apply to selected central inflow approaches after exposure and should not be extended automatically to patients requiring bypass before resternotomy.
Limitations and Disclosures
This was a nonrandomized retrospective study from one institution with only 34 innominate patients. Selection bias, surgeon preference, different cerebral-perfusion methods, changing practice over time, and limited statistical power restrict causal conclusions. Details of previous operations, atheroma burden, and intraoperative vessel quality were incomplete. Approximately 26% of patients lacked cooling/rewarming or oximetry data, further limiting those comparisons.
The authors call for prospective studies with standardized imaging and monitoring. Cleveland reports consulting and a study investigator relationship with Abbott; Aftab and Reece report consulting relationships with several cardiovascular device companies. The remaining authors report no conflicts.
Original Article
Wu BCB, Tsai MH, Rosenberg DS, et al. Aortic and innominate cannulations are equally safe in redo aortic surgery. JTCVS Open. 2026;33:102086. doi:10.1016/j.xjon.2026.102086.
This independently written educational summary accompanies the unchanged open-access source PDF, published under CC BY-NC-ND 4.0. The cover is an AI-generated editorial illustration.
