Improving Circulatory Support in Cases of Acute DeBakey Type I Aortic Dissection: A Novel Arterial Cannulation Approach and Its Effects on Perfusion and Minimizing Complications

Objective . Proposing a novel arterial cannulation technique for acute DeBakey type I aortic dissection with severe aortic arch and branch involvement to enhance CPB efectiveness and reduce organ malperfusion complications. Methods . Te technique involves retrograde insertion of an arterial perfusion tube into the aortic arch through the left common carotid artery. Extra-corporeal circulation is established, and total aortic arch replacement with deep hypothermic systemic circulation and a frozen elephant trunk stent placement are performed to restore lower body perfusion. Results . Six patients with severe aortic arch and branch involvement underwent the new arterial cannulation technique. All patients had smooth postoperative recoveries without signifcant complications. Conclusion . Te novel arterial cannulation technique shows promise in managing acute DeBakey type I aortic dissection with extensive vascular involvement, reducing complications, and enhancing patient outcomes. Further validation with a larger patient cohort is needed to confrm its efectiveness and safety. If successful, this technique could become a valuable addition to treatment strategies for improved outcomes.


Introduction
Acute DeBakey type I aortic dissection is a critical cardiovascular condition characterized by a sudden onset and a high case fatality rate [1].Urgent intervention is necessary to prevent severe complications and mortality.Currently, traditional arterial cannulation methods, such as femoral artery cannulation, axillary artery cannulation, apical cannulation, and left subclavian artery cannulation, are employed in the treatment of aortic dissection [2,3].However, these conventional approaches pose challenges for patients with extensive involvement of the aortic arch and its three branches.Tese methods can result in elevated intraoperative perfusion pressure, excessive cerebral perfusion, and inadequate systemic organ perfusion [4].Tese factors are closely associated with poor patient outcomes.
Te aim of this article is to propose a novel arterial cannulation strategy for patients with severe involvement of the aortic arch and its three branches.Te objective is to facilitate the application and adoption of this new arterial cannulation technique in clinical practice, thereby improving treatment outcomes and enhancing the quality of life of patients with acute DeBakey type I aortic dissection.

Methodology
A median sternal incision was made to expose the brachiocephalic trunk, left common carotid artery, and left subclavian artery.Te extracorporeal circulation pipeline, three-branch perfusion tube, and puncture catheter were prepared (Figure 1(a)).
Initially, the venous tube was inserted into the right atrium, followed by transection of the proximal end of the left common carotid artery.Te arterial perfusion tube was then inserted into the aortic arch.After confrming thoracic artery fow using colour ultrasound (Figure 1(b)), cardiopulmonary circulation was established.For cerebral perfusion, the distal end of the left common carotid artery was connected to the branch perfusion tube (Figure 1(d)).
Once the nasopharynx temperature reached 25 °C, the perfusion tube of the brachiocephalic trunk and the branch of the left subclavian artery were inserted.Te aortic arch was then cut of, circulation in the lower body was stopped, and antegrade cerebral perfusion was initiated at a rate of 5-8 ml/kg/min.Te frozen elephant trunk stent was released into the true lumen of the descending aorta.Te distal end of the elephant trunk was anastomosed with the covered stent in an end-to-end fashion, allowing for restoration of lower body perfusion through the fourth branch of elephant trunk.Te proximal end of the artifcial vessel was anastomosed with the aortic root in an end-to-end fashion.Following rewarming, the left subclavian artery, left common carotid artery, and brachiocephalic trunk were sequentially anastomosed.
Tis method was utilized for cardiopulmonary bypass in six patients with severe involvement of the aortic arch and its branches.

Results
In this clinical study, a novel arterial cannulation technique was applied to six patients with acute DeBakey type I aortic dissection and severe involvement of the aortic arch and its branches.Te average age of the patients was 48.7 ± 17.3 years, with a male-to-female ratio of 2 : 1.Most patients presented with hypertension (83.3%) and had aortic involvement of less than 50% with signifcant compression of the true lumen in the aortic arch and its three branches.Surgical methods included Bentall procedure with aortic arch replacement and descending aortic stent implantation (16.7%) or replacement of the ascending aorta with aortic arch and stent placement in the descending aorta (83.3%).
Using the novel technique, successful extracorporeal circulation was achieved in all patients, with an average circulation time of 214.8 ± 11.3 minutes and aortic occlusion time of 135.0 ± 11.9 minutes.Te average nasopharyngeal temperature during surgery was maintained at 25.4 ± 0.6 °C, indicating successful deep hypothermic systemic circulation.
Postoperative recovery was uneventful for all patients, with an average ICU stay of 6.8 ± 2.2 days.Extubation was achieved at an average of 27.83 ± 12.54 hours after surgery, and patients showed good bed mobility, with an average duration of 4.5 ± 1.0 days.Tree cases (50.0%) experienced pleural efusion, but no other major complications were observed, including cerebral infarction, myocardial infarction, heart failure, postoperative delirium, paraplegia, secondary thoracotomy, incision infection, or liver and kidney dysfunction.
Te novel arterial cannulation technique demonstrated favorable outcomes in managing acute DeBakey type I aortic dissection with extensive vascular involvement.Although the study has a limited sample size and lacks a control group, the results are promising.Further investigation with a larger patient cohort is warranted to validate the efectiveness and safety of this approach fully.If proven successful, this technique has the potential to become a valuable addition to treatment strategies for improving outcomes in such cases.
Preoperative planning through a thorough analysis of aortic CTA images and bedside vascular ultrasound played a crucial role in determining the suitability of the novel technique for patients with severe vascular involvement.Te specifc true luminal involvement of the aortic arch and its three supra-arch branches for each patient is detailed in Table 1.
Table 2 summarizes the preoperative, intraoperative, and postoperative parameters, while Figure 1 illustrates the various steps involved in the novel arterial cannulation technique during extracorporeal circulation and aortic root surgery.

Discussion
Te smooth establishment of cardiopulmonary bypass (CPB) is a prerequisite for the implementation of vascular replacement surgery and plays a pivotal role in aortic dissection surgery.Choosing the location of cannulation based on vascular involvement is the core of establishing extracorporeal circulation.At present, the axillary artery, femoral artery, femoral axillary joint, central artery, apex of heart, and other parts are often used clinically for arterial intubation [5], but for patients with obvious involvement of the aortic arch and three branches above the arch, conventional intubation methods have the risk of poor organ perfusion and related complications, such as cerebral infarction, paralysis, and delayed recovery, which seriously afect the postoperative rehabilitation and the long-term quality of life of patients [6].Since January 2022, a new arterial cannulation technique to establish cardiopulmonary bypass has been implemented at our centre.Te technique was frst implemented in 6 patients who were treated at our centre.In this technique, the sequence of the cardiopulmonary bypass is adjusted, an arterial perfusion tube is retrogradely inserted into the aortic arch through the left common carotid artery, and the aortic blood substitute tube is replaced.In our clinical practice, the incision of the axillary artery and femoral artery was not lengthened in any of the six patients, and no obvious complications occurred during or after the operation.All of the patients recovered and were discharged from the hospital, indicating that this new intubation method has achieved good clinical efcacy and helps to reduce the occurrence of intraoperative and postoperative complications in such patients as well as 2 Journal of Cardiac Surgery  Journal of Cardiac Surgery  Journal of Cardiac Surgery improve the prognosis of such patients.In summary, we have tentatively attempted to establish a new arterial cannulation method for extracorporeal circulation to complete the surgery.In the future, we plan to include more patients for exploration and process improvement to further confrm the efectiveness and safety of this arterial cannulation method.

Table 1 :
True luminal involvement of the aortic arch and three supra-arch branches.