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Eur J Cardiothorac Surg 2002;22:313-315
© 2002 Elsevier Science NL

How-to-do-it

Axillary artery cannulation for arterial inflow in patients with acute dissection of the ascending aorta

Department of Cardiovascular Surgery, Bursa Yüksek Ihtisas Teaching and Research Hospital, Duacinari-16330, Bursa, Turkey

Received 28 December 2001; received in revised form 7 April 2002; accepted 10 April 2002.

* Corresponding author. Tel.: +90-224-360-5050; fax: +90-224-360-5055
e-mail: syavuz64{at}yahoo.com

	Abstract

Top Abstract 1. Introduction 2. Technique 3. Results 4. Discussion References

 
The axillary artery is an alternative site for arterial cannulation that avoids manipulation of the ascending aorta or aortic arch and provides antegrade blood flow during surgery for acute type A aortic dissection. Right axillary artery cannulation has been used in 27 patients for arterial perfusion. There were no complications related to the technique of axillary cannulation. All patients but one awoke neurologically intact from operation and suffered no complications. Hospital mortality occurred in two (7.4%) patients. Axillary cannulation is easy to establish and may safely be used for arterial inflow during surgery for acute type A dissection of the ascending aorta.

Key Words: Aortic dissection • Axillary artery • Cannulation • Arterial inflow • Cardiopulmonary bypass

	1. Introduction

Top Abstract 1. Introduction 2. Technique 3. Results 4. Discussion References

 
The choice of an adequate, non-diseased cannulation site for arterial inflow during cardiopulmonary bypass (CPB) is an important point, in particular for dissections involving the ascending aorta, the aortic arch and/or the abdominal aorta. These pathological conditions demand the use of a distant arterial site of cannulation for CPB inflow [1–6].

It may be difficult to find a safe site for placement of a perfusion cannula when performing surgery of ascending aorta and aortic arch for acute type A aortic dissection [2,3]. Cannulation of the possibly dissected vessels might induce irreparable damage.

Pressurization of the false lumen and subsequent brain and visceral malperfusion is one of the most severe complication for patients with acute dissection by using femoral arterial perfusion. In order to minimize the risk of malperfusion caused by retrograde flow during CPB, femoral cannulation should be avoided. To overcome these disadvantages, arterial perfusion through the axillary artery may be a good alternative.

We herein report our experience with axillary cannulation.

	2. Technique

Top Abstract 1. Introduction 2. Technique 3. Results 4. Discussion References

 
A transverse skin incision, 8–10 cm in length running from a point just lateral to the sternal head of the clavicle to the upper deltopectoral grove, is made below the clavicle to expose the right axillary artery (Fig. 1) .

View larger version (30K): [in this window] [in a new window]   Fig. 1. Exposure of the right axillary artery. Infraclavicular exposure of the axillary vessels is best obtained through an incision of 8–10 cm in length running from a point just lateral to the sternal head of the clavicle to the upper deltopectoral grove.

After heparinization femoral artery clamps are used proximal and distal to the site of cannulation. A single 5-0 polypropylene (Prolene, Ethicon Ltd., Edinburgh, UK) purse-string suture is placed surrounding the arteriotomy and passed through a tourniquet.

Through a transverse arteriotomy, the axillary artery is cannulated with either 20F or 22F straight flexible arterial cannula (Jostra Arterial Cannulae, JOSTRA Medizintechnik AG, Hirrlinfen, Germany). It is inserted and advanced 3–4 cm into the artery being removed by the proximal clamp. The tip of the cannula should not obstruct the orifice of the right common carotid artery. The cannula is tied to the tourniquet and sutured to the skin. After evaluating the flow through the cannula by back-bleeding it is connected to the CPB pump tubing circuit. At the end of CPB the artery is allowed to back-bleed to ensure that no thrombus is present. Preferably, the artery is then primarily repaired using an interrupted 6-0 Prolene suture.

	3. Results

Top Abstract 1. Introduction 2. Technique 3. Results 4. Discussion References

 
Axillary artery cannulation has been used in 27 patients for arterial perfusion in surgical repair for acute type A dissection involving the ascending aorta.

Direct cannulation has been applied in all patients. There were no complications related to the technique of axillary cannulation. No patient had weakness and numbness of the right arm caused by brachial plexus alteration and there were no vascular injuries. False channel perfusion, however, has not been a problem in our experience with axillary cannulation.

The mean circulatory arrest time was 25.8 min (range 10–43 min), the mean retrograde cerebral perfusion time was 23 min (range 9–41 min), and the mean CPB time was 156.7 min (range 72–293 min).

One (3.7%) patient, who had mentally obtunded preoperatively, had suffered transient confusion postoperatively, which resolved spontaneously within 12 h after extubation. No focal neurologic deficits were detected in the remaining patients. Hospital mortality occurred in two (7.4%) patients due to intestinal ischemia and multiorgan system failure, respectively, 3 and 20 days after operation.

	4. Discussion

Top Abstract 1. Introduction 2. Technique 3. Results 4. Discussion References

 
Axillary cannulation eliminates the necessity for a separate groin incision and avoids the malperfusion of the cannulated leg that can occur when the femoral artery is used for retrograde perfusion. Unlike the femoral artery, because of the rich collateral network of the scapular region, occlusion of the axillary artery does not cause severe digital ischemia or reperfusion injury unless there is associated embolization [2,3,5–7].

The axillary artery may be cannulated directly or through a 8 mm Dacron side-arm. Direct axillary cannulation is more expeditious, and an advantage in patients with type A aortic dissection [2,3,5,6]. If the axillary artery is fragile, a graft interposition technique avoids the trauma of direct cannulation. It also allows perfusion of the arm and avoids the malperfusion of the vertebral artery during CPB. In addition, this technique facilitates decannulation, which is accomplished simply by transecting the Dacron graft and oversewing the stump [4,5]. Stenosis of the artery is also avoided at closure by tailoring the proximal graft as a patch in the graft interposition technique. However, it is more difficult to evacuate air from the graft than from the cannula, and this may be disadvantageous.

Good clinical results related to axillary cannulation have been reported [3,4–6]. In our experience, we had seen no local infections, drainage, brachial plexus injuries, or vascular compromise. Furthermore, false-channel perfusion has not been a problem in our patients.

Unlike the potential advantages of axillary cannulation, there are some potentially fatal complications [8]. Acute dissection involving the subclavian and axillary artery may potentially result in malperfusion. If a perfusion cannula is advanced a little more, it may obstruct the common carotid artery. Thus, it leads to inadequate flow and even brain ischemia.

Axillary cannulation is easy to perform, and does not increase the risk of the procedure [1–6]. It offers the advantage of antegrade perfusion with standard aortic cannulation when the ascending aorta and arch aorta are unavoidable in aortic dissection.

	References

Top Abstract 1. Introduction 2. Technique 3. Results 4. Discussion References

 

1. Borst H.G. Surgical tactics and techniques. In: Borst H.G., Heinemann M.K., Stone C.D., eds. Surgical treatment of aortic dissection, 1st ed. New York: Churchill Livingstone, 1996:255-268.
2. Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D.M. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-891.[Abstract]
3. Bichell D.P., Balaguer J.M., Aranki S.F., Couper G.S., Adams D.H., Rizzo R.J., Collins R.J., Jr., Cohn L.H. Axilloaxillary cardiopulmonary bypass: a practical alternative to femorofemoral bypass. Ann Thorac Surg 1997;64:702-705.[Abstract/Free Full Text]
4. Baribeau Y.R., Westbrook B.M., Charlesworth D.C., Maloney C.T. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg 1998;66:33-37.[Abstract/Free Full Text]
5. Whitlark J.D., Goldman S.M., Sutter F.P. Axillary artery cannulation in acute ascending aortic dissections. Ann Thorac Surg 2000;69:1127-1129.[Abstract/Free Full Text]
6. Neri E., Massetti M., Capannini G., Carone E., Tucci E., Diciolla F., Prifti E., Sassi C. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999;118:324-329.[Abstract/Free Full Text]
7. Van Arsdell G.S., David T.E., Butany J. Autopsies in acute type A aortic dissection: surgical implications. Circulation 1998;98(Suppl):II299-II304.
8. Imanaka K., Kyo S., Tanabe H., Ohuchi H., Asano H., Yokote Y. Fatal intraoperative dissection of the innominate artery due to perfusion through the right axillary artery. J Thorac Cardiovasc Surg 2000;120:405-406.[Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Senol Yavuz Tamer Türk Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yavuz, S. Articles by Türk, T. Search for Related Content PubMed PubMed Citation Articles by Yavuz, S. Articles by Türk, T. Related Collections Cardiac - other Cerebral protection Extracorporeal circulation Great vessels