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Eur J Cardiothorac Surg 2005;27:634-637
© 2005 Elsevier Science NL

Technical problems and complications of axillary artery cannulation

Department of Cardiac Surgery, Innsbruck University Hospital, Anichstrasse 35, A-6020 Innsbruck, Austria

Received 20 July 2004; received in revised form 12 November 2004; accepted 29 December 2004.

^* Corresponding author. Tel.: +43 512 504 80820; fax: +43 512 504 22528. (E-mail: thomas.schachner{at}uibk.ac.at).

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: Cardiopulmonary bypass via the axillary artery is frequently used especially in aortic dissections. With an increased use of this technique problems were recognized too. We describe the technical problems and complications associated with axillary artery cannulation. Methods: Sixty-five patients underwent cannulation of the axillary artery. The indication for operation was acute aortic dissection type A in 57%, chronic aortic dissection in 8%, aortic aneurysm in 18%, pseudoaneurysm in 3%, and others in 14%. Results: Technical problems and complications occurred in 14%, and in 11% the perfusion had to be switched to either femoral (n=5) or aortic cannulation (n=2). Arterial damage or dissection of the axillary artery or the aorta occurred in 0% of the sidegraft technique, whereas they were found in 9% with direct cannulation (P=n.s.). Cannulation problems or insufficient CPB flow due to a narrow vessel occurred in 0% of the sidegraft technique, whereas they were found in 4% with direct cannulation (P=n.s.). Malperfusion in aortic dissections occurred in 20% of the sidegraft technique, whereas they were found in 0% with direct cannulation (P=0.016). No postoperative complications related to axillary cannulation which were evaluated by clinical examination, such as brachial plexus injury, axillary artery thrombosis or local wound infection were observed. Conclusions: Although axillary artery cannulation is an attractive alternative to femoral cannulation there needs to be an alertness for technical problems. Different complications occur with either direct cannulation or the sidegraft technique and at present it remains the surgeons preference which technique for axillary artery cannulation is used.

Key Words: Axillary artery • Cardiopulmonary bypass • Axillary artery cannulation • Malperfusion

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Cardiopulmonary bypass (CPB) via the axillary artery has become an alternative perfusion site especially in acute aortic dissections and patients with severe aortic atherosclerosis [1–7]. Despite several advantages of axillary artery cannulation such as antegrade perfusion of the aorta, problems and complications of this technique are getting known with increased use. It is still a matter of discussion which technique of axillary artery cannulation should be used: direct cannulation or the sidegraft technique [8,9].

It was the aim of our study to describe our experience with technical problems and complications of axillary artery cannulation and their association with the cannulation technique.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
2.1. Patients
Between July 2000 and June 2004 (except one case in 1998) 65 patients underwent cannulation of the axillary artery at our institution. The median age was 63 (22–81) years and 74% of the patients were male. The indication for operation was acute aortic dissection type A in 37/65 (57%), chronic aortic dissection in 5/65 (8%), aortic aneurysm in 12/65 (18%), pseudoaneurysm in 2/65 (3%), and others (e.g. severe atherosclerosis of the ascending aorta with coronary artery disease or aortic stenosis, aortic valve regurgitation after previous ascending aortic replacement) in 9/65 (14%) of the patients. About 39/65 (60%) were performed as acute cases and 11/65 (17%) were reoperations.

2.2. Surgical technique
The perfusion via the axillary artery was performed as previously described [1,5]. In brief the axillary artery was exposed via a right infraclavicular approach. After clamping of the vessel and longitudinal arteriotomy either direct cannulation with a 20F or 22F straight cannula (DLP, Medtronic, Inc.) or an end-to-side anastomosis of an 8mm Gore-Tex graft was performed (sidegraft technique). The distal clamp on the axillary artery remained in case of direct cannulation, and it was removed in case of sidegrafting.

After decannulation the axillary artery was closed longitudinally using a 6/0 Prolene running suture or reconstructed with a Gore-Tex patch if the vessel diameter appeared to become narrowed with direct closure.

2.3. Statistical analysis
The SPSS software (SPSS 11.0) for windows was used for statistical analysis. Categorical variables are given as percentages continuous variables are presented as median and range. In univariate analysis qualitative variables were analyzed using chi-square tests. Results were considered statistically significant at P values of less than 0.05.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
The operations performed are listed in Table 1. The median cardiopulmonary bypass (CPB) time was 203 (46–569)min, the median aortic cross clamp time was 113 (38–220)min. Hypothermic circulatory arrest (HCA) was used in 52/65 (80%) cases with a median circulatory arrest time of 35 (15–79)min. In four patients HCA was conducted at moderate hypothermia (at a body temperature of 24°C) with antegrade cerebral perfusion, whereas in 48 patients deep hypothermic circulatory arrest was performed (at a body temperature of 18°C, as determined by urinary bladder thermocatheter). Retrograde cerebral perfusion was performed in 23/65 (35%), and antegrade cerebral perfusion in 11/65 (17%) patients.

Perfusion via the axillary artery was attempted in 65 patients (Fig. 1). In 20 cases the sidegraft technique was used, and in 45 cases direct cannulation was performed. Aortic dissection was present in 15/20 (75%) sidegraft cases, and in 27/45 (60%) cases of direct cannulation (P=0.24). Technical problems and complications occurred in 9/65 (14%) cases and were categorized into three groups (Table 2).

View larger version (26K): [in this window] [in a new window]   Fig. 1. Number of axillary artery cannulations either with direct cannulation or with sidegraft technique per year.

The following associations between surgical technique of axillary perfusion (i.e. direct cannulation or sidegraft technique) and categories of technical problems and complications could be found.

Group 1 problems (arterial damage or dissection of the axillary artery or the aorta) occurred in 0/20 (0%) cases of the sidegraft technique, whereas they were found in 4/45 (9%) cases with direct cannulation (P=n.s.). Group 2 problems (cannulation problems or insufficient CPB flow due to a narrow vessel) occurred in 0/20 (0%) cases of the sidegraft technique, whereas they were found in 2/45 (4%) cases with direct cannulation (P=n.s.). Group 3 problems (malperfusion in aortic dissections) occurred in 3/15 (20%) cases of the sidegraft technique, whereas they were found in 0/27 (0%) cases with direct cannulation (P=0.016).

No postoperative complications related to axillary cannulation which were evaluated by clinical examination, such as brachial plexus injury, axillary artery thrombosis or local wound infection were observed.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
During the last years the use of axillary artery cannulation has led to bigger series and an increased experience with this technique. Furthermore technical problems and complications of axillary cannulation were determined and quantified [1–9, Table 3].

In our series in 14% of the cases technical problems occurred (a very detailed prospective documentation may be one cause of this high rate), and in about 1/10 the cannulation had to be switched to either femoral or aortic perfusion. We categorized the problems into three groups.

4.1. Arterial injury
We experienced axillary artery injury in 5%. In literature this complication ranges between 0 [2,3,6] and 2% [9]. This is probably due to the fact that we included even small injuries that could be fixed with one or a few repair stitches. And the series with 0% of axillary artery injury contained 27 cases or less.

A new aortic dissection occurred in one of our patients who had severe aortic atherosclerosis and underwent axillary cannulation to perform CABG without aortic cannulation. The perfusion was switched immediately to the femoral artery and the patient underwent ascending aortic replacement and CABG. The patient survived the procedure. Sabik and co-workers [9] report a rate of new aortic dissections of 1% of axillary artery cannulations. In our experience arterial injury occured only in patients with direct cannulation of the axillary artery, which can be explained by the manipulation by the cannula itself.

4.2. Cannulation problems/low CPB flow
In one of our patients the (direct) cannulation of the axillary artery was impossible because of significant resistance in the artery during advancement of the cannula. In this case, we switched to femoral cannulation, another option would probably be the use of the sidegraft technique in axillary cannulation. Cannulation problems of the axillary artery are described in literature in a range of 1–10% [1,7,8]. A low CPB flow was present in one of our patients after axillary cannulation, and the perfusion was switched to aortic cannulation. This is in accordance with Sabik and co-workers [9] who report this problem in 1% of axillary CPB access.

4.3. Malperfusion
One major indication for axillary artery cannulation is acute aortic dissection, due to the rare involvement of the axillary artery into the dissection. However, we experienced malperfusion in three cases. All three cases were acute aortic dissections type A, and after initiation of CPB via the axillary artery a decreased blood pressure in the left radial artery and/or the femoral artery pressure line was noticed. The perfusion was switched to the femoral artery and pressures were again equalized. Interestingly all three cases of malperfusion occurred with the sidegraft technique of axillary artery cannulation, and statistical significance was reached. However, it remains to be elucidated why the malperfusion occurred only with this technique.

Postoperatively we found no local wound infection, no arm ischemia/compartment syndrome, and no brachial plexus injury as determined by clinical examination. This is in agreement with other authors findings (compare Table 3) and it is one advantage of axillary artery cannulation.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

1. Schachner T, Vertacnik K, Laufer G, Bonatti J. Axillary artery cannulation in surgery of the ascending aorta and the aortic arch. Eur J Cardiothorac Surg 2002;22:445-447.[Abstract/Free Full Text]
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5. Schachner T, Laufer G, Vertacnik K, Bonaros N, Nagiller J, Bonatti J. Is the axillary artery a suitable cannulation site in aortic surgery?. J Cardiovasc Surg 2004;45:15-19.[Medline]
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8. Sinclair MC, Singer RL, Manley NJ, Montesano RM. Cannulation of the axillary artery for cardiopulmonary bypass: safeguards and pitfalls. Ann Thorac Surg 2003;75:931-934.[Abstract/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): Thomas Schachner Johannes Bonatti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schachner, T. Articles by Bonatti, J. Search for Related Content PubMed PubMed Citation Articles by Schachner, T. Articles by Bonatti, J. Related Collections Extracorporeal circulation Great vessels