1.Femoral artery cannulation (**Figure 5**)

For many years, it has been the cannulation site of choice [22]. Allowing rapid access, it is usually used in hemodynamically unstable patients, especially with impending cardiac tamponade and aortic rupture. It is important to mark the femoral artery before skin preparation as it may be difficult to localise it during hypotension. Common femoral artery is situated medial and inferior to the midpoint of the inguinal ligament. An oblique or vertical incision may be used for exposure [23]. An open Seldinger technique is quick and can be performed with minimal dissection. Advantages of this approach include (i) cardiopulmonary bypass is established quickly, (ii) easy to access with a closed chest, (iii) less likely to be dissected, (iv) prevents aortic rupture in patients with cardiac tamponade. Disadvantages include (i) stroke and malperfusion due to dynamic obstruction and (ii) retrograde perfusion leading to embolic complications due to atherosclerotic emboli. The femoral artery with a dissection flap is not used for cannulation.

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**Figure 6.**

*Axillary artery cannulation.*

*Current and Future Management Strategies of Type A Aortic Dissection*

*DOI: http://dx.doi.org/10.5772/intechopen.93015*

2.Axillary artery cannulation (**Figure 6**)

**Figure 5.**

*Femoral artery cannulation.*

injury to brachial plexus nerves.

3.Central aortic cannulation:

Introduced in 1990s [24], axillary artery cannulation is gaining greater acceptance among surgeons as they switch to an antegrade perfusion strategy. It is more commonly used in hemodynamically stable patients. Infraclavicular dissection exposes the first part of axillary artery [25]. The pectoralis major muscle is split. The neurovascular bundle is situated deep in the clavipectoral fascia. The deltopectoral approach exposes the second and third parts for cannulation [26]. The axillary artery can be directly cannulated or anastomosed with end to side 8 mm vascular graft. Advantages include (i) antegrade perfusion flow and (ii) can be used for antegrade cerebral perfusion by occluding innominate artery. Disadvantages of this approach include (i) takes more time than femoral cannulation especially in obese patients and (ii) technically more difficult and risk of

Locating a site where the chances of not entering into the false lumen is the most critical part. It can be done with TEE, CT or epiaortic scanning. Cannulation can be performed with Seldinger technique or directly. Advantages include (i) CPB

*Current and Future Management Strategies of Type A Aortic Dissection DOI: http://dx.doi.org/10.5772/intechopen.93015*

**Figure 5.** *Femoral artery cannulation.*

*Advances in Complex Valvular Disease*

**6. Surgical strategies**

ready for use.

**7. Cannulation strategies**

is not used for cannulation.

1.Femoral artery cannulation (**Figure 5**)

pressures.

**6.1 Preparation for surgery**

1.Blood pressure (BP) control: One of the most important pre-requisites of successful outcome is very strict control of BP. Systolic BP should be less than 110 mmHg. It can be lowered using intravenous beta blocker (esmolol) or combined alpha & beta receptor antagonists (labetalol) or glyceryl trinitrate. Intravenous adrenaline should be used in patients presenting with cardiogenic shock and cardiac tamponade. Anaesthetic induction is also another step where BP should be tightly controlled. Commonly used medications include Fentanyl, isoflurane and glyceryl trinitrate. Peri-operatively, a target systolic blood pressure of 90–110 mmHg, mean arterial pressure of 60 mmHg, and

central venous pressure of 8–12 mmHg are recommended [21].

2.Coagulation status: Aortic dissection activates inflammatory, coagulation and fibrinolytic pathways leading to disseminated intravascular coagulation. Consumption coagulopathy is worsened in some patients by inadvertently prescribing aspirin, clopidogrel by misdiagnosing these patients as having acute coronary syndromes. Hence, adequate amounts of packed red blood cells, platelets, fresh frozen plasma and cryoprecipiate should be kept

3. 2 arterial lines (both arms) should be placed to monitor differential blood

5.Invasive monitoring of intracranial pressure by lumbar catheter (occasionally)

For many years, it has been the cannulation site of choice [22]. Allowing rapid access, it is usually used in hemodynamically unstable patients, especially with impending cardiac tamponade and aortic rupture. It is important to mark the femoral artery before skin preparation as it may be difficult to localise it during hypotension. Common femoral artery is situated medial and inferior to the midpoint of the inguinal ligament. An oblique or vertical incision may be used for exposure [23]. An open Seldinger technique is quick and can be performed with minimal dissection. Advantages of this approach include (i) cardiopulmonary bypass is established quickly, (ii) easy to access with a closed chest, (iii) less likely to be dissected, (iv) prevents aortic rupture in patients with cardiac tamponade. Disadvantages include (i) stroke and malperfusion due to dynamic obstruction and (ii) retrograde perfusion leading to embolic complications due to atherosclerotic emboli. The femoral artery with a dissection flap

Also include a femoral arterial line to monitor distal perfusion pressures

4.Cerebral oxygenation monitoring by near—infrared spectroscopy

**66**
