Is axillary superior to femoral artery cannulation for acute type A aortic dissection surgery?

A best evidence topic was written according to a structured protocol. The question addressed was whether axillary artery cannulation (AXC) is superior to femoral artery cannulation (FAC) in patients undergoing surgical repair of acute type A aortic dissection. A total of 90 studies were identified using the reported search, of which 10 represented the best evidence to answer the clinical question. There were nine retrospective studies and one meta-analysis. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Four papers, including the meta-analysis, reported significantly increased mortality in patients undergoing surgery with FAC. From these, two papers, again including the meta-analysis, reported also significantly increased neurological dysfunction, and another one demonstrated significantly increased incidence of postoperative bleeding and sternal infections in this same group of patients. Two more studies reported decreased mortality, malperfusion and neurological complications in patients undergoing surgical repair with AXC, but no statistical analysis was performed. Three reports comparing AXC and FAC found no difference between the two groups in terms of operative mortality and major complications, while another one demonstrated increased incidence of postoperative mortality in patients undergoing surgery with AXC, most likely due to the presence of malperfusion of one or more organs preoperatively in those who died. Patients undergoing repair of type A aortic dissection may benefit from AXC, whenever this is technically feasible. Most reports show that inflow perfusion through the axillary artery will reduce overall mortality, and neurological and malperfusion complications when compared with FAC. However, it needs to be stressed that, in three reports, the superiority of AXC over FAC might be attributed to the fact that patients in the latter group were critically ill in haemodynamic collapse. Nevertheless, this indicates that the femoral artery remains a bailout option in the emergency situation when institution of cardiopulmonary bypass is required rapidly.