Dr B. Rylski (Freiburg, Germany): Please could you explain what your criteria is for ascending cannulation versus femoral cannulation? When you cannulate dissected ascending aorta, there is a risk of false lumen cannulation. After opening of the aortic arch, you can easily assess whether the aortic cannula is positioned in the true or in the false lumen. Could you tell us in how many patients did you cannulate the false lumen? Most surgeons do not use this access considering the risk of aortic

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... upture, false lumen cannulation, or embolization risk. Did you observe any of these complications in this big series of patients? Dr Klotz: Yes, great questions. Regarding the second question, it's correct. I will not say aortic cannulation is dangerous. We saw it, at least what I know, twice in patients with resuscitation in the operation room. We just did the sternotomy and the aortic cannulation with an anaesthesiologist in the night which was not so confirmed to see a guidewire in the TOE. Both patients had false lumen cannulations and false lumen perfusion. One patient died in the operation room and the other patient we just clamped the aorta, pull the cannula out, put all the venous blood in the drainage, and opened the aorta and did a directly cannulation in the aortic arch and started perfusion again. For the first question, we don't have absolute rules. It's depending on the surgeon, on the status of the patient and on the anaesthesiologist on call during the night. Type A dissections are mostly in the night. The standard approach is subclavian artery; however, if the patient is obese or haemodynamically unstable, we just go for the femoral artery. So with this data presented here, we could show that our results with femoral artery cannulation are not worse than the subclavian artery, so we just go to the femoral arteries. It's an easily accessible site, and we don't have any pain trying to find the subclavian artery and then doing a side branch or just direct cannulation of the subclavian artery because you just go to the femoral artery. Dr M. Grabenwöger (Vienna, Austria): Maybe you see no difference because you cooled down all patients below 20°C. I think the advantage of the subclavian artery is when you are operating in moderate hypothermia with antegrade perfusion and then maybe you can find the difference. If you cool down to 18°C, I'm with you, maybe there is no difference.