Outcomes of cannulation strategies under antegrade cerebral perfusion in type a aortic dissection surgery: a systematic review and meta-analysis

OBJECTIVE: Arterial cannulation strategies remain a topic of debate in type A aortic dissection (ATAAD) repair surgery due to their variability and the inconsistent use of concomitant cerebral perfusion techniques. This study aims to compare clinical outcomes associated with different arterial cannulation strategies in patients undergoing ATAAD repair with antegrade cerebral perfusion (ACP). METHODS: A systematic literature search was conducted to identify studies comparing clinical outcomes of at least two arterial cannulation strategies (subclavian, femoral or direct aortic) in ATAAD repair surgery with ACP. Primary outcomes were both early mortality and postoperative stroke (in-hospital events or within 30-days after surgery). RESULTS: Six studies were included from 921 screened, comprising 1694 subclavian, 315 femoral, and 132 direct cannulation cases. The underlying patient characteristics of within-study comparisons were not balanced. Especially the femoral-subclavian comparison was characterized by more presenting symptoms (cardiac tamponade, hemodynamic shock) in the femoral group. Subclavian cannulation was associated with significantly lower early mortality compared to femoral cannulation (OR:0.64,95%CI:0.44-0.93, p = 0.022), but no significant difference in favor of direct cannulation was observed (OR:0.82,95%CI:0.37-1.85, p = 0.13) or between femoral and direct aortic cannulation (OR: 1.80, 95% CI: 0.22-15.33; p = 0.15). No significant differences in early postoperative stroke incidence were observed among the strategies: subclavian vs. femoral (OR:0.91,95%CI:0.55-1.49, p = 0.72), direct vs. femoral (OR:0.63, 95%CI:0.18-2.12, p = 0.45), and direct vs. subclavian (OR: 0.69,95%CI:0.19-2.51, p = 0.81). CONCLUSIONS: In acute type A aortic dissection surgery with antegrade cerebral perfusion, existing evidence is limited by confounding from patient risk profiles and lack of power. Early mortality was lower with subclavian cannulation compared to femoral cannulation. No significant differences were observed between other strategies, although the direction of effect suggests a potential benefit of direct over femoral cannulation. Larger, adequately powered studies are needed to define technique-specific benefits in different patient subgroups.