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Eur J Cardiothorac Surg 2004;26:831-833
© 2004 Elsevier Science NL

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Cannulation of the brachiocephalic trunk during surgery of the thoracic aorta: a simplified technique for antegrade cerebral perfusion

Department of Cardiac Surgery, GM Lancisi Hospital, Via Conca 71 60020, Ancona, Italy

Received 10 February 2004; received in revised form 12 May 2004; accepted 1 July 2004.

^* Corresponding author. Tel.:+39-071-596-5300; fax: +39-071-596-5371. (E-mail: m_dieus{at}hotmail.com).

	Abstract

Top Abstract 1. Introduction 2. Surgical technique 3. Discussion References

 
Here we present our simplified technique of cannulation of the brachiocephalic trunk for cardiopulmonary bypass and antegrade cerebral perfusion institution.

	1. Introduction

Top Abstract 1. Introduction 2. Surgical technique 3. Discussion References

 
During surgery of the thoracic aorta, optimal methods of cerebral protection are necessary to avoid ischemic/embolic brain injuries.

Antegrade Selective Cerebral Perfusion (ASCP) is currently our method of choice since provides the following advantages:

• A safe circulatory arrest up to 90min [1]

• the extent of the aortic replacement has no impact on hospital mortality and neurologic outcome [1]

• lower transient neurologic dysfunction rates [2]

• better pulmonary and function recovery after surgery [3]

• moderate instead of deep hypothermia may be used [4,5] with reduced periods of CPB.

To reduce the brain embolic risk, alternative cannulation sites such as the ascending aorta, the right/left axillary artery have been employed and often preferred to the femoral artery. These central cannulation sites share in common the avoidance of retrograde perfusion of the thoraco-abdominal aorta intended as a source of embolic material destined to the cerebral vascularization. Furthermore, during acute dissection repair, they may be effective in reducing the risk of brain/organ malperfusion.

Here we describe our technique of cannulation of the brachiocephalic trunk for CPB and ASCP during surgery of the thoracic aorta.

	2. Surgical technique

Top Abstract 1. Introduction 2. Surgical technique 3. Discussion References

 
The arch vessels and the aortic arch were exposed through a standard sternotomy incision. After systemic heparinization, the brachiocephalic trunk was partially side-clamped 4–5cm distal to its origin from the aortic arch. During this manoeuvre, an adequate distal perfusion to the right arm and right cerebral circulation was ensured by monitoring the right radial artery pressure. An 8-mm Hemashield vascular graft was anastomosed in an end-to-side fashion to the brachiocephalic trunk and connected to the arterial line using a 22 F cannula (Fig. 1). Atriocaval cannulation was used for venous return. A left vent drain was positioned through the right superior pulmonary vein. Cardiopulmonary bypass was instituted and cooling initiated. As indicated by Kazui and colleagues our cerebral perfusion protocol include moderate hypothermia (rectal temperature: 22–24°C) and a cerebral perfusion flow of 10ml/kg per min adjusted to keep a right radial arterial pressure between 40 and 70mmHg [4,5]. Thus, at a rectal temperature of 22–24°C, the brachiocephalic trunk was clamped, the pump flow was reduced to 5ml/kg per min, the aorta was opened and a 15 F coronary sinus perfusion cannula, connected to the oxygenator through a separate roller pump, was introduced in the left common carotid artery with a flow of 5ml/kg per min (Fig. 2). Tools of cerebral monitoring included the right radial pressure and the regional oxygen saturation in the bilateral frontal lobes by means of a near-infrared spectroscopy. After completing the arch reconstruction, the innominate artery clamp was removed and after de-airing the extracorporeal circulation was reinstituted in an antegrade fashion trough the same artery.

View larger version (182K): [in this window] [in a new window]   Fig. 1. Brachiocephalic trunk cannulation with a graft interposition technique. (a) Brachiocephalic artery graft; (b) ascending aorta; (c) innominate vein; (d) saccular aortic arch aneurysm.

View larger version (148K): [in this window] [in a new window]   Fig. 2. Antegrade cerebral perfusion. (a) Brachiocephalic artery clamp; (b) left subclavian artery clamp; (c) cerebral perfusion cannula in the left common carotid artery; (d) samp sucker into the descending thoracic aorta; (e) brachiocephalic artery graft; (f) opened saccular aortic arch aneurysm.

	3. Discussion

Top Abstract 1. Introduction 2. Surgical technique 3. Discussion References

 
In the last decade, advances in cerebral protection with ASCP together with the selection of central cannulation sites have provided improved results in patients undergoing surgery of the thoracic aorta [1,2,6].

The standard cannulation of the femoral artery carries high risk of malperfusion in patients with acute dissection and high risk of debris dislodgment and retrograde brain embolization in patients with atherosclerotic thoraco-abdominal aorta.

Thus, more central cannulation sites such as the ascending aorta and the right/left axillary artery have been proposed to reduce these detrimental complications [6,7].

The cannulation of the right axillary artery may facilitate the aortic procedure and provide some advantages when using ASCP [8]. In fact, the axillary artery is generally free from atherosclerosis and dissection, ASCP is never stopped, the risk of air embolism during the carotid cannulation is reduced because of the back flow through the left carotid artery, bihemispheric perfusion is assured having only one ASCP cannula in the operating field, CPB can be reinstituted in an antegrade fashion without the need of graft cannulation. Use of a graft interposition technique allows to monitor cerebral perfusion through the same graft by reading the right radial artery pressure.

In 10 cases (chronic aneurysm, n=8, acute dissection n=2) we have selected the brachiocephalic trunk as a site for arterial inflow. This technique provides all the above-mentioned advantages of the right axillary artery cannulation, but with a greater simplicity. Indeed, there is no need of an adjunctive incision required to prepare the axillary artery with reduced time for CPB institution, and lower risk of local infections, drainage, brachial plexus or vascular compromise.

The selection of the adequate cannulation site on the brachiocephalic trunk was in all cases 4–5cm distal to the origin from the aortic arch where the likelihood of dislodging material is low, and indicated by an accurate evaluation of the arterial wall quality by CT scan and/or epiaortic scan.

During acute dissection repair the brachiocephalic trunk was not involved by the dissection.

In conclusion, the brachiocephalic trunk may represent an adjunctive site for cannulation during surgery of the thoracic aorta. Absolute—but not frequent in the clinical setting—contraindications may include: (a) dissection extending distal to the brachiocephalic trunk; (b) bad quality of the brachiocephalic trunk for calcification and/or atheroma.

	References

Top Abstract 1. Introduction 2. Surgical technique 3. Discussion References

 

1. Di Eusanio M, Schepens MA, Morshuis WJ, Di Bartolomeo R, Pierangeli A, Dossche KM. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg 2002;124:1080-1086.[Abstract/Free Full Text]
2. Hagl C, Ergin MA, Galla JD. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients. J Thorac Cardiovasc Surg 2001;121:1107-1121.[Abstract/Free Full Text]
3. Di Eusanio M, Wesselink RMJ, Morshuis WJ, Dossche KM, Schepens MAAM. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta/hemiarch replacement: a retrospective comparative study. J Thorac Cardiovasc Surg 2002;125:849-854.
4. Tanaka H, Kazui T, Sato H, Inoue N, Yamada O, Komatsu S. Experimental study on the optimum flow rate and pressure for selective cerebral perfusion. Ann Thorac Surg 1995;59:651-657.[Abstract/Free Full Text]
5. Kazui T, Kimura N, Yamada O, Komatsu S. Surgical outcome of aortic arch aneurysms using selective cerebral perfusion. Ann Thorac Surg 1994;57:904-911.[Abstract]
6. Kazui T, Washiyama N, Muhammad BA, Terada H, Yamashita K, Takinami M. Improved results of atherosclerotic arch aneurysm operations with a refined technique. J Thorac Cardiovasc Surg 2001;121:491-499.[Abstract/Free Full Text]
7. Westaby S, Katsumata T. Proximal aortic perfusion for complex arch and descending aortic disease. J Thorac Cardiovasc Surg 1998;115:162-167.[Abstract/Free Full Text]
8. Mazzola A, Gregorini R, Villani C, Di Eusanio M. Antegrade cerebral perfusion by axillary artery and left carotid artery inflow at moderate hypothermia. Eur J Cardiothorac Surg 2002;21:930-931.[Abstract/Free Full Text]

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				H. Gulbins, A. Pritisanac, and J. Ennker Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation? Ann. Thorac. Surg., March 1, 2007; 83(3): 1219 - 1224. [Abstract] [Full Text] [PDF]

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): Michele D. Pierri Giuseppe Di Eusanio Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Di Eusanio, M. Articles by Di Eusanio, G. Search for Related Content PubMed PubMed Citation Articles by Di Eusanio, M. Articles by Di Eusanio, G. Related Collections Cerebral protection Extracorporeal circulation Great vessels