Samurai (the Direct True Lumen Technique) Cannulation in Acute Type I Aortic Dissection

Background 

Arterial cannulation strategy in type I aortic dissection remains challenging, especially for hemodynamically unstable patients or those with dissection extending into the innominate artery. This video provides an overview of the steps involved in the direct true lumen (DTL) cannulation technique. 

Methods 

 After a median sternotomy and full heparinization, a two-stage venous return cannula was inserted into the right atrium, and a left ventricular vent was introduced via the right upper pulmonary vein. The ascending aorta was carefully mobilized and circumferentially dissected, with two Mersilene tapes passed around the ascending aorta for later aortic line snaring. The patient was placed in a deep Trendelenburg position and then exsanguinated into cardiopulmonary bypass (CPB) venous reservoir to achieve systolic arterial pressure of 20-30 mmHg (no pulse wave). The ascending aorta was completely transected under direct vision in the area just above the sinotubular junction, and the true lumen was identified. A straight arterial cannula with low-flow perfusion was inserted into the true lumen and snared gently with Mersilene tapes. An expeditious total hypothermic CPB with precooling priming solution was initiated with antegrade flow into the true lumen. Subsequently, selective antegrade cardioplegia was performed through the coronary ostia. Pressure monitoring in both radial arteries and femoral arteries with bilateral cerebral oxygen saturation measurement were used to identify intraoperative malperfusion. 

Results 

From April 2004 to September 2022, the technique of open DTL cannulation of the ascending aorta was applied in 185 patients. In all cases, the true lumen was identified, and no adverse effects associated with malferfusion were detected. However, in this series, late reoperations occurred in group patients due to technical failures specifically related to the initial phase of the learning curve. These failures included major aortic root bleeding due to manipulation, ascending aorta rupture before placing or securing Mersilene tapes, and true lumen obstruction with clots during insertion. The actual 30-day hospital mortality was 21.6 percent, mainly associated with extensive full arch surgery (58.3 percent), with the leading cause being multiple organ disfunction syndrome. New permanent neurologic events after surgery were diagnosed in 11.3 percent of patients. 

Conclusions 

Direct ascending aorta true lumen cannulation is a fast, safe, and reproducible technique that provides adequate central antegrade flow through the true aortic lumen within two minutes of circulatory arrest. 

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