Corrado Cavozza

Objectives: Direct innominate artery cannulation is a viable and effective alternative for arterial inflow during thoracic aorta surgery, applicable in elective and emergent cases. This technique ensures reliable circulatory control. Methods: A single-center retrospective study of 208 cases that underwent thoracic aortic surgery between January 2010 and December 2021 was performed. The primary outcomes were in-hospital and remote mortality and the secondary outcomes were adverse neurologic events. Results: The median age of the patients was 69 years. The male gender accounted for 63.9% of the cases. The most represented surgical interventions consisted of hemiarch replacement in 105 cases (50.5%) and ascending aorta and aortic valve replacement (wheat procedure) in 71 cases (34.1%). The operative mortality rate was 5.3%, with six cases attributed to aortic-type dissection. The overall remote mortality rate at five years was 7.7. Postoperatively, 70 patients experienced alterations in the level of consciousness, with 12 of these cases belonging to the dissection group. Six patients with permanent neurologic symptoms had a positive computed tomography scan. Of the eleven patients with negative brain computed tomography scans, nine experienced temporary neurological deficits, while two suffered from permanent neurological damage. Conclusions: Direct innominate artery cannulation represents a safe and effective method for providing arterial inflow during cardiopulmonary bypass, offering an outstanding alternative to traditional sites for both planned and urgent surgical interventions.

Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed.

Surgical management of aortic dissection is technically challenging for different reasons. Reapproximation of dissected layers because of fragility of the dissected aortic wall layers is of major concern. Many techniques have been described to restore the integrity of aortic wall. Inclusion of a partially resorbable mesh fixed with glue, between the dissected layers, may be a simple and effective method for providing a secure and viable end-to-end anastomosis between aortic stump and a Dacron graft.

Several cannulation sites alternative to the ascending aorta, such as femoral, right axillary, carotid, innominate artery, and, less commonly, apical sites, have been proposed. Cannulation of the right subclavian artery, through sternotomy, is one possible means of establishing cardiopulmonary bypass, hence avoiding a second surgical incision. In our experience, cardiopulmonary bypass flow was adequate and circulatory arrest with antegrade cerebral perfusion was successfully performed in all cases. There was no in-hospital mortality.