An alternative technique for cannulation in type A dissection.

In a recent issue, there was a Great Debate article about cannulation techniques in patients with type A dissection complicated by cerebral malperfusion [1]. Paul P. Urbanski argues for cannulation of the common carotid artery by using a separate incision along the medial margin of the sternocleidomastoid muscle. Jean Bachet gives arguments for the right axillary artery as cannulation site by an infraclavicular opening. It is not mentioned that these approaches can be combined by extending the sternal incision into the right side of the jugulum. The common carotid—and the right subclavian artery (which becomes the axillary artery at the lateral border of the first rib)—can be exposed, and cannulation performed by attaching a graft to one of these arteries, preferably to the subclavian artery as the cerebral circulation is interrupted to a lesser degree. The disadvantage is the scar in the jugulum compared with a more unseen scar located below the clavicula. On the other hand, the axillary cannulation can be somewhat time-consuming, particularly in obese and very muscular individuals. In addition, many type A dissection patients have an element of cardiac tamponade at operation and there will be no delay in relieving this by the proposed approach.