Does cannulation site affect outcomes of antegrade cerebral perfusion in aortic arch surgery? A meta-analysis of axillary versus innominate access

Background The optimal arterial cannulation strategy for establishing antegrade cerebral perfusion during aortic arch surgery remains a subject of ongoing debate. Our meta-analysis compares outcomes between axillary artery (AxA) and innominate artery (InA) cannulation. Methods A literature search was conducted for studies that compared AxA and InA cannulation in aortic surgery. RevMan 8.13.0 was used to calculate effect estimates reported as odds ratios (OR) and mean differences (MD), with their 95% confidence intervals (CI). Subgroup analyses were performed for (a) randomised controlled trials (RCT) and propensity-matched cohorts, (b) elective cases, and (c) emergent cases. Results We included seven studies comprising 1763 patients, of whom 1063 (60%) underwent AxA cannulation. AxA cannulation was associated with significantly longer cardiopulmonary bypass (CPB) time than InA cannulation [MD 23.7 min; 95% CI 9.7 to 37.8; p < 0.001]. ICU stay [MD 0.4 days; 95% CI −0.2 to 1.1; p = 0.21] and hospital stay [MD 0.5 days; 95% CI −0.3 to 1.4; p = 0.23] were comparable. No significant differences were observed in 30-days mortality [OR 1.1; p = 0.55], stroke [OR 1.3; p = 0.43], seizure [OR 0.8; p = 0.81], acute kidney injury [OR 1.4; p = 0.18], delirium [OR 0.8; p = 0.64], or reoperation for bleeding [OR 1.3; p = 0.51]. Subgrou p analyses of elective and emergent cases confirmed the CPB time difference, with no significant differences in other clinical outcomes. Conclusions While AxA was associated with longer CPB time, other clinical outcomes were comparable between the two cannulation strategies, suggesting that InA cannulation may represent a safe and efficient alternative in selected cases. However, due to surgical heterogeneity, predominance of observational data, and low-certainty evidence for most outcomes, we cannot establish true equivalence and thus our findings should be interpreted cautiously and validated by future randomised controlled trials.