336. Cannulation Strategy in Reoperative Aortic Surgery: Central Versus Peripheral Cannulation
Mary A. Siki, Madeline B. Koelsch, *Joseph E. Bavaria, *Prashanth Vallabhajosyula, *Wilson Y. Szeto, *Nimesh D. Desai
University of Pennsylvania, Philadelphia, PA
Invited Discussant: *Anthony L. Estrera
Objective: Reoperative aortic surgery is known to be associated with higher periprocedural morbidity and mortality. Due to increased scarring and possibility for aortic injury, finding an optimal cannulation site can be challenging in these cases, and in some instances surgeons may choose to use peripheral cannulation. Therefore, we looked to study the safety of direct ascending cannulation compared to peripheral cannulation in patients undergoing reoperative surgery.
Methods: A retrospective review was conducted using data from our institutional database from January 1, 2002 to June 30, 2016. Among 489 redo-aortic surgery patients, 387 underwent central aortic cannulation and 102 underwent peripheral aortic cannulation (femoral or axillary artery). Univariate analysis was performed using Fisher’s Exact Test and student’s t-test. Univariate 1-year survival analysis was performed using Kaplan-Meier Survival estimates. Multivariate logistic regression was used to determine predictors of 30-day mortality.
Results: Mean age was similar between central and peripheral cannulation groups (58.8±14.8 vs. 61.8±13.8 years, p=0.06). Patients in the peripheral cannulation group were generally sicker than those in the central cannulation group, with higher incidence of hypertension, history of renal failure, and urgent or emergent operative status. Both groups had similar cardiopulmonary bypass times, but patients in the peripheral cannulation group were more likely to undergo circulatory arrest [88.2% (n=67) vs. 59.8% (n=147), p<0.0001]. Patients in the peripheral cannulation group had a higher 30-day mortality rate [17.7% (n=18) vs. 7.24% (n=28), p=0.002] and were more likely to have postoperative renal failure (p=0.01), prolonged ventilation times (p<0001), permanent stroke (p=0.04), longer lengths of stay (p<0.0001). Kaplan-Meier survival estimates also showed patients in the peripheral cannulation group had higher mortality out to 1-year (p=0.005). In a multivariate logistic regression increasing age (OR 1.03, 95% CI 1.002-1.06), emergent operative status (OR 4.49, 95% CI 1.96-10.26), NYHA Class IV heart failure (OR 2.47, 95% CI 1.04-5.87), previous CABG (OR 3.60, 95% CI 1.08-12.02), previous CABG and Valve procedure (OR 4.26, 95% CI 1.11-16.32), or previous aortic surgery (OR 3.10, 95% CI 1.04-9.31) were shown to be predictive of 30-day mortality. Cannulation strategy was not predictive of 30-day mortality.
Conclusions: Central cannulation is a safe and reliable approach for redo-aortic surgery. Peripheral cannulation was used in sicker patients with more complex arch pathology. Patients with previous CABG and patients requiring emergency surgery had poorer outcomes likely related to patient pathology.