Long-term outcomes of common carotid artery cannulation for elective aortic surgery-a follow-up study

Abstract

Background: The selection of the cannulation site for elective aortic surgery is mostly an individual choice based on the surgeon's experience and the surgical strategy. We evaluated the long-term outcomes of right common carotid artery (CCA) cannulation using a side graft to establish unilateral selective antegrade cerebral perfusion (uSACP).

Methods: We reviewed the records of 343 patients who underwent elective ascending aortic or aortic arch surgery between 2013 and 2020. One hundred aortic procedures were performed using the right CCA as the sole arterial cannulation site under moderate hypothermic circulatory arrest (MHCA). Cross-validated least absolute shrinkage and selection operator (LASSO) and stepwise Cox regression were applied to model the effects of cannulation sites on adverse outcomes. Kaplan-Meier analysis compared mortality in the treatment group with that in the general population.

Results: The mean patient age was 65.9±9.5 years (81% male). The mean MHCA temperature was 27.1±5.1 ℃, and the average uSACP duration was 13.6±7.7 minutes. The early mortality and stroke rates were 1% and 4%, respectively. After a median of 5.4 follow-up years, seven patients suffered stroke, with 92% survival at 6 years, similar to an age- and gender-matched general population (log-rank P=0.50). Multivariable analysis revealed that age at surgery was the only significant predictor of late stroke or death [hazard ratio (HR) =1.083; P=0.01; c-index 0.683). Control Doppler ultrasound examination after a median of 2.3 years found no evidence of injury or dissection of the right CCA.

Conclusions: Cannulation of the right carotid artery is a safe, feasible, and practical adjunct technique for proximal aortic surgery that generates comparable short- and long-term results. Careful patient selection and techniques are essential to minimize risk.

Keywords: Selective antegrade cerebral perfusion (SACP); aortic surgery; common carotid artery (CCA).

Figure 1

Central image—the actual operative site with carotid cannulation and exposure of the aorta through an upper-hemisternotomy approach.

Figure 2

Laboratory analysis (hepatic function tests and kidney parameters). (A) Hepatic laboratory studies showing initial increase in hepatic enzymes and subsequent normalization towards discharge. (B) Kidney parameters in the postoperative course: decline in GFR followed by normalization towards discharge. AP, alkaline phosphatase; LDH, lactate dehydrogenase; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GFR, glomerular filtration rate.

Figure 3

Kaplan-Meier survival curve for patients after elective aortic surgery using the right common carotid artery as an arterial cannulation site and comparison with age- and gender-matched population in Bavaria, Germany.

Figure 4

Kaplan-Meier event-free survival curve for composite event of stroke and death in follow-up.