The selection of the arterial cannulation site for institution of cardiopul-monary bypass is a critical point during surgery for acute aortic dissection. Historically, in these patients the femoral artery has been adopted as primary site for arterial access15. However, a number of relevant complications have been associated with this procedure, including propagation of a retrograde dissection, retrograde embolization of lumen debris, and malperfusion causing end-organ ischemia16-18. In particular, cerebral injury can occur during retrograde blood-flow perfusion due to occlusion of the origin of the supra-aortic arterial trunks by the aortic false lumen or by a subtotal occlusion in the descending aorta by a thrombosed false lumen (Figure 17.1). The right axillary artery, on the other hand, has been found to be involved in the dissection only rarely and also is seldomly affected by extensive atherosclerotic lesions, so commonly found in the femoral artery18-21. The utilization of this artery has been developed as a safe access. Axillary artery cannulation secures continuous antegrade blood flow in the true lumen, avoiding the phenomenon of the compressed true channel. Also, this access eliminates the extra surgical step of having to cannulate the aortic graft after distal aortic reconstruction to have an antegrade aortic perfusion after completion of the distal anastomosis. In cases of small or deeply placed axillary arteries, a side graft of 8-12 mm can be used to avoid damage to the artery or inadequate flow, particularly in large, overweight male patients20,22,23. Most important, arterial inflow through the axillary artery facilitates the use of selective cerebral perfusion during open aortic surgery, which can be directly administrated through the right common carotid artery, occluding the innominate artery (Figure 17.2). For the usefulness in reducing perfusion-related morbidity and adverse outcome in AAAD patients, the right axillary artery cannulation is becoming increasingly widespread, representing the preferred site of arterial perfusion in many centers21-23.
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