Abstract
Aortic arch surgery remains associated with significant mortality and morbidity especially in the setting of acute type A aortic dissection. Adequate cerebral protection is essential, and several methods have been proposed to avoid neurological injury during aortic arch surgery. The most common techniques include selective antegrade perfusion of brachiocephalic arteries or an interval of deep hypothermic circulatory arrest. A range of cannulation strategies have been employed safely to provide adequate cerebral protection. Optimal cannulation selection is based on the consideration of air or particulate embolism risk; limitation in operative field visibility; end organ perfusion; and interactions with surgical maneuvers. Overall, no technique has been shown to fully mitigate the risk of neurological injury, rather each has utility in different scenarios. Innominate artery cannulation offers high flows on CPB and avoids additional incisions. Right axillary artery is rarely involved in aortic dissections, versatile for use in redo surgery, and altered blood flow patterns reduce embolic stroke rates. Left axillary artery can be utilized when both right axillary and femoral arteries are involved in a dissection process. Novel bi-axillary approach has additionally shown good results. Future multicenter, randomized trials should focus on establishing the relative benefits and risks of each cannulation approach with the aim of delineating the optimal cannulation strategy for different clinical situations to guide aortic surgeons, particularly in the emergency setting of aortic dissection.