Cerebral protection remains a cornerstone of successful outcomes in aortic surgery, where the interruption of blood flow can lead to irreversible neurological damage. Traditionally, selective antegrade cerebral perfusion (SACP) via axillary artery (AX) cannulation has been the standard approach. However, AX cannulation can be complex, carries a risk of complications like brachial plexus injury and limb ischemia, and requires additional incisions. In light of these limitations, a recent retrospective study published in the Journal of Clinical Medicine evaluates the feasibility, safety, and clinical outcomes of innominate artery (IA) graft cannulation as an alternative technique for SACP during proximal aortic surgery.
This study analyzed 196 patients who underwent IA graft cannulation between January 2021 and June 2024. Patients included those undergoing elective and emergency procedures, such as for Type A acute aortic dissection (TAAAD) and Marfan syndrome (MFS), ensuring the findings apply across varied high-risk populations. The main objective was to assess postoperative complications, such as stroke, delirium, mortality, and acute renal failure (ARF), and to determine the efficacy of IA cannulation in minimizing these risks.
The surgical approach involved attaching a 10 mm Dacron side graft to the mid-segment of the IA and connecting it to the arterial return line. This setup allowed consistent blood flow with a wider diameter than standard cannulas, resulting in optimized systemic and cerebral circulation. The side graft’s size reduced arterial resistance and likely enhanced cooling and rewarming efficiency, thereby shortening cardiopulmonary bypass (CPB) times.
Median CPB, cross-clamp, and SACP durations were 120.5, 93, and 23 minutes, respectively. The most common surgical procedure was ascending aorta and hemiarch replacement (36.74%), followed by coronary bypass and valve replacements. Postoperative complications were minimal: 30-day mortality was 3.06%, stroke occurred in only 2.04% of cases, and ARF was observed in 3.06%. Delirium, which was more broadly defined in this study, was reported in 9.18% of patients, but all resolved within 2–3 days.
Particularly notable were the outcomes in high-risk groups. Among 36 TAAAD patients, the mortality rate was 8.33%, with only one stroke case. The MFS group, although requiring longer surgeries like the Bentall procedure, had a mortality rate of just 4.35% and no reported strokes. These results are promising, considering the inherent risks associated with these conditions.
IA graft cannulation, according to the authors, offers multiple advantages over AX cannulation. First, it eliminates the need for infraclavicular incisions, minimizing surgical trauma. Second, it reduces the risk of vascular injury and embolism associated with direct IA cannulation. Finally, the side graft allows for high-flow perfusion while maintaining cerebral protection, even in patients with large body surface areas and high cardiac output.
Compared to existing literature, this study’s complication rates are favorable. Stroke and mortality rates remained within or below published ranges for similar techniques. The design of the study, including strict inclusion and exclusion criteria, contributed to consistent surgical outcomes. Patients with IA or carotid artery pathologies were excluded, ensuring safety and homogeneity in the cohort.
Despite these strengths, the study has limitations. It is retrospective and single-center in nature, limiting the generalizability of findings. Intraoperative cerebral oxygen saturation data were not consistently recorded, and no direct comparison was made with other perfusion strategies, such as AX or direct IA cannulation. The definition of postoperative delirium was broader than in other studies, potentially inflating its reported incidence.
Nevertheless, the study provides strong preliminary evidence supporting the use of IA graft cannulation as a primary method for cerebral perfusion in aortic surgery. Its simplicity, safety profile, and adaptability to high-risk surgical scenarios make it a compelling alternative to more traditional methods. Furthermore, the ability to integrate this technique without extending surgical time or increasing risk suggests potential for widespread clinical adoption.
Future directions include larger multicenter, prospective studies that compare IA graft cannulation directly with AX and direct IA methods. Additionally, long-term neurological and renal outcomes should be assessed to fully establish the technique’s efficacy. As the landscape of aortic surgery evolves with new technologies and techniques, the IA graft approach represents a significant step forward in optimizing patient outcomes and surgical efficiency.
Study ranking = 3 (moderate quality; strong data set from a single center but retrospective without control group or randomization)
