Alternative cannulation techniques in surgical repair for acute type A aortic dissection

In this issue of the European Research Journal, Yalcin et al. [1] reported an experience with ascending aorta cannulation for surgical repair in a case with acute type A aortic dissection (AAAD). This presentation raises many questions that should be answered by the authors. They reported direct true lumen cannulation of the ascending aorta under visual control but this technique has not clearly been explained in detail. How was the aortic cannula introduced? What was arterial systolic pressure before procedure? Was venous exsanguination from the right atrium performed? The answers to these questions have not been explicitly stated in the text. Another very important issue is cerebral protection. There is also no an information about protection of the brain during the open distal anastomosis. The technique has not satisfactorily been discussed. Despite all these shortcomings, the authors are to be congratulated on their successful dissection repair with this technique and for bringing it to our attention. I would also like to share additional comments on alternative cannulation techniques for arterial inflow in these complicated patients. AAAD is one of the life-threatening cardiovascular conditions and associated with an increased risk of mortality and morbidity. It requires immediate surgical intervention to avoid catastrophic complications such as aortic rupture or organ malperfusion (brain or visceral). The most important stages for succesful surgical treatment of AAAD include the excision of the primary entry tear in the aorta, the elimination of aortic valve insufficiency, and the establishment of the true lumen flow to correct the distal malperfusion [2]. The best arterial cannulation site for a prompt induction of CPB in surgical repair of AAAD remains controversial [3]. The most important objective for the arterial cannulation in this lethal condition is to allow antegrade blood flow through the true lumen. The choice of arterial inflow site is influenced by many factors including hemodynamic instability (cardiac tamponade or shock), the presence of malperfusion, the extent of dissection, possible involvement of the cannulation site, peripheral vascular disease, a history of stroke, the patient’s age or the preference of the surgeon. Many different inflow sites for arterial cannulation have been described. Possible access points for cannulation include the femoral artery, the axillary artery, the brachial artery, the innominate artery, the carotid artery, the subclavian artery, the ascending aorta, the transverse arch of the aorta, and the left ventricular apex. Each cannulation site has both the advantages and disadvantages [3]. In current cardiovascular practice, the femoral arteries and the axillary arteries are the most commonly used cannulation sites for repair of AAAD. Excellent results have been reported with these arterial inflow sites [4-6]. Femoral artery cannulation is the standard cannulation technique and allows for the rapid institution of CPB in hemodynamically unstable patients with AAAD. However, it has disadvantages of retrograde arterial perfusion such as an increased risk of retrograde cerebral embolization due to atherosclerotic debris or thrombus in the descending