A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery

Published:November 30, 2020DOI:



      Cerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy.


      To compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery.


      This randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, Identifier: NCT02554032), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke.


      One hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups.


      diffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      ACE CardioLink-3 (Aortic Surgery Cerebral Protection Evaluation CardioLink-3), ACP (antegrade cerebral protection), CPB (cardiopulmonary bypass), DW-MRI (diffusion-weighted magnetic resonance imaging), HCA (hypothermic circulatory arrest), MRS (Modified Rankin Scale), NSE (neuron-specific enolase), RCTs (randomized controlled trials), S100β (S100 calcium-binding protein β), TIA (transient ischemic attack)
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      Linked Article

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      • Commentary: Innominate artery cannulation for antegrade cerebral perfusion: Keeping the light bulb lit
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          Peterson and colleagues1 report the results of a randomized trial comparing axillary versus innominate artery cannulation for antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) in 111 patients undergoing proximal aortic arch surgery. The primary safety outcome was the presence of new severe ischemic lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) and was no different in patients cannulated via the axillary artery (38.8%) or innominate artery (34%). Secondary safety outcomes of stroke/transient ischemic attack were also similar between groups (7.1% axillary and 3.6% innominate; P = .43), as were neurocognitive assessments.
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