The Aortic Surgery Cerebral Protection Evaluation (ACE) Randomized CardioLink-3 Trial

Study Overview
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Brief Summary
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The ACE trial is a multicentre, randomized controlled trial comparing axillary vs. innominate artery cannulation for established antegrade cerebral perfusion in patients having aortic surgery (thoracic and aortic arch) requiring deep hypothermic circulatory arrest using a non-inferiority trial design.

Detailed Description
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Surgery on the thoracic aorta often requires a brief period of deep hypothermic circulatory arrest (DHCA). The most feared complication of aortic surgery is neurological injury, which can range from mild cognitive impairment to more severe injuries such as stroke. Due to the significant morbidity and mortality associated with post-operative stroke and neurological dysfunction, cerebral protection techniques have evolved extensively. A recommended approach to cerebral protection during DHCA is to deliver blood to the brain in an antegrade fashion via the arterial system, so called antegrade cerebral perfusion (ACP). Axillary artery cannulation, a form of ACP, has become the preferred method of neuroprotection for aortic operations requiring DHCA. However, axillary artery cannulation requires more surgical time and presents potential complications such as brachial plexus injury, seromas, and limb ischemia. The present study aims to determine whether a less common alternative strategy, innominate artery cannulation, offers similar neuroprotection compared to axillary artery cannulation and reduces operative times. A total of 110 patients undergoing elective aortic surgery will be randomly assigned to one of the two strategies. The primary outcome will be the number of patients with new ischemic lesions found on post-operative diffusion weighted MRI (DW-MRI) and total operative time.

Official Title
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A Randomized Controlled Trial of Axillary vs. Innominate Artery Cannulation for Antegrade Cerebral Protection in Aortic Surgery: The ACE Randomized Trial

Conditions
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Aortic Aneurysm, Thoracic

Intervention / Treatment
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* Procedure: Axillary artery cannulation
* Procedure: Innominate artery cannulation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥ 18 years. Elective aortic arch operation. Planned open distal anastamosis with deep hypothermic circulatory arrest. Exclusion Criteria: Patients undergoing surgery for aortic dissection or urgent/emergent operation. Patients undergoing surgery for total aortic arch replacement. Patients who are unable to undergo MRI scan (such as due to claustrophobia). Use of an investigational drug or device at the time of enrolment Participation in another clinical trial which interferes with performance of the study procedures or assessment of the outcomes

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Axillary artery cannulation<br>Axillary artery cannulation for antegrade cerebral perfusion | Procedure: Axillary artery cannulation<br>* The right axillary artery will be exposed via an infraclavicular incision and a Dacron graft sewn to it in an end to side fashion after 5000 units of IV heparin. Following median sternotomy and full systemic heparinization, CPB will be initiated and the patient cooled. The base of the innominate artery will be clamped, and antegrade cerebral perfusion will be provided via the axillary artery. Following completion of the distal open aortic anastomosis, the clamp on the innominate artery will be removed, CPB via the aorta will be resumed and the patient will be rewarmed. After completion of surgery and weaning from CPB, the axillary artery graft will then be removed, the artery repaired and the skin will be closed.<br>|
| Active Comparator: Innominate artery cannulation<br>Innominate artery cannulation for antegrade cerebral perfusion | Procedure: Innominate artery cannulation<br>* After median sternotomy, systemic heparinization, cannulation of the ascending aorta and right atrium, CPB and systemic cooling will be initiated. The ascending aorta, proximal arch and the base of the innominate artery will be mobilized. Purse-string sutures are placed on the anterior wall of the proximal innominate artery and a pediatric venous cannula inserted using a J wire and sequential dilatation. Circulatory arrest with ACP is provided by clamping the base of the innominate artery and connecting the afferent limb of the CPB circuit to the innominate cannula. Once the distal aortic anastomosis is completed, ACP is discontinued, and full CPB via the aortic graft is resumed. Rewarming and the remaining surgery are then completed.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| new severe ischemic lesions | The primary safety endpoint of this trial is the proportion of patients with new severe ischemic lesions found on post-operative DW-MRI compared with pre-operative MRI. | Post-operative day 4 | 
| Total operative time | The primary efficacy endpoint of this trial is the difference in total operative time between the innominate artery cannulation group and the axillary artery cannulation group. | Intra-operative | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| all-cause mortality |  | 30-day | 
| Stroke or TIA (transient ischemic attack) |  | 30-day | 
| Neurocognitive dysfunction | Montreal Cognitive Assessment (MOCA) and Mini-Mental State Examination (MMSE) | Post-operative day 4 | 
| Number of new ischemic lesions | assessed by DW-MRI | Post-operative day 4 | 
| Volume of new ischemic lesions | assessed by DW-MRI | Post-operative day 4 | 
| Intracerebral hemorrhage | assessed by DW-MRI | Post-operative day 4 | 
| S100B and Neuron Specific Enolase | Post-operative serum level of circulating biomarkers of neuronal injury | 24 hours post-op | 
| Post-operative sepsis, delirium, seizure, encephalopathy, atrial fibrillation, post-operative myocardial infarction, re-operation |  | 30-day | 
| Seroma, brachial plexus injury, reduced arm mobility and pain, arm ischemia |  | 30-day | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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antegrade cerebral perfusion, innominate artery cannulation, axillary artery cannulation, aortic surgery, deep hypothermic circulatory arrest