Eur J Cardiothorac Surg 2007;32:270-273. doi:10.1016/j.ejcts.2007.03.050
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Cannulation of the innominate artery during surgery of the thoracic aorta: our experience in 55 patients
Marco Di Eusanio*,
Michele Ciano,
Giuseppe Labriola,
Giosuè Lionetti,
Giuseppe Di Eusanio
Department of Cardiovascular Surgery, Santa Maria Hospital, Bari, Italy
Received 29 January 2007;
received in revised form 22 March 2007;
accepted 26 March 2007.
* Corresponding author. Address: Department of Cardiovascular Surgery, Santa Maria Hospital, Via de Ferrariis 18/D, 70124 Bari, Italy. Tel.: +39 080 5040190(O)/335 8168588(R); fax: +39 080 5040190. (Email: m_dieus{at}hotmail.com).
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Abstract
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Background: Alternative cannulation sites such as the right/left axillary artery, the ascending aorta and aortic arch have been recently preferred to the femoral artery to improve neurologic outcome in patients undergoing surgery of the thoracic aorta. In 2004, we started to select the innominate artery as an arterial cannulation site for CPB and antegrade cerebral perfusion institution. Here we present our preliminary experience with 55 patients. Methods: Between November 2004 and 2006, 55 patients (mean age 60 ± 14 years) underwent surgery on the thoracic aorta using the innominate artery as a site for arterial cannulation. Indication for surgery was a degenerative aneurysm in 49 (89.1%), an acute type A dissection in 2 patients (3.6%), a post-dissection aneurysm in 3 (5.4%), a supravalvular aortic stenosis in 1 patient (1.8%). Operative procedure included total arch replacement (n
= 9), hemiarch replacement (n
= 6), ascending aorta replacement (n
= 21), Bentall procedure (n
= 18) and aortoplasty with patch (n
= 1). Mean CPB and cross clamp times were 131 ± 60 and 95 ± 29 min, respectively. Mean cerebral perfusion time was 54 ± 26 min. Results: The hospital mortality rate was 3.6%. There were no permanent neurologic dysfunction and one (1.8%) temporary neurological dysfunction. Conclusion: Our results with the cannulation of the innominate artery were encouraging. This provides the same advantages of the axillary artery cannulation with greater simplicity and avoiding extra surgical incisions which may be site for local complications. It may represent a valid option for CPB and antegrade cerebral perfusion institution in aortic procedures.
Key Words: Aortic surgery • Cerebral protection
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1. Introduction
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It has been demonstrated that during surgery of thoracic aorta the cannulation of the right axillary artery (RAA) or ascending aorta (AA) provides improved outcome as compared to the cannulation of the femoral artery [1–4].
In 2004, we started to select the innominate artery (IA) as a site for cardio pulmonary bypass (CPB) arterial inflow and antegrade cerebral perfusion (ACP) when required [5]. In the present study, we present our experience with 55 patients.
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2. Materials and methods
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2.1 Patients’ profile
Between November 2004 and 2006, 55 patients underwent operative procedures on the thoracic aorta using the IA as a site for arterial cannulation and ACP institution when required.
There were 33 men (60%) and 22 women (40%) whose age ranged from 20 to 83 years (mean 60 ± 14 years). Indication for surgery included degenerative aneurysm in 49 (89.1%), acute type A dissection in 2 patients (3.6%), post-dissection aneurysm in 3 (5.4%), a supravalvular aortic stenosis in 1 patient (1.8%). Associated diseases are depicted in Table 1
. The predicted hospital mortality by EuroScore system was 7.0 ± 2.5% (range 3–12).
All patients underwent preoperative evaluation of the thoracic aorta and epiaortic vessels with angio-CT scan. All elective patients underwent evaluation of cerebral circulation with Doppler ultrasound of the extra-cranial vessels, digital subtraction angiography and/or angio-CT scan of the extra-cranial and intra-cranial circulations.
Continuous variables were expressed as mean ± 1 SD and categorical variables as percentages.
2.2 Operative technique
The aorta, the epiaortic vessels and the innominate vein (which was always preserved) were exposed through a standard median sternotomy. After systemic heparinization, cannulation of the IA and right atrium was performed for CPB institution. The left side of the heart was vented through the right superior pulmonary vein. Myocardial protection was achieved with blood cardioplegia. Details of our cannulation technique of the IA have been previously described [5]. Briefly, after the IA was exposed from its origin to the bifurcation, it was partially side-clamped 4–5 cm distal to its origin. An 8 mm (or 10 mm) vascular graft was anastomosed in an end-to-side fashion to the IA and connected to the arterial line using a 22 F cannula (Fig. 1
). In three cases, the IA was directly cannulated (without a graft interposition) using a 22 F side-holes cannula (Soft Flow, Terumo, SarnsTM) (Fig. 2
). After CPB establishment, the procedure was carried out as usual. Patients requiring replacement of the aortic arch and ACP were cooled to nasopharyngeal 25 °C, the IA and the left subclavian artery (LSA) were gently clamped, the pump flow was reduced to 5 ml/(kg min) and adjusted to maintain a right radial artery pressure of 40–70 mmHg, 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 5 ml/(kg min). Brain perfusated was maintained at the temperature of 20 °C and the lower body was never perfused during the aortic arch reconstruction. After completing the arch reconstruction, the IA and LSA clamps were removed and after de-airing, the extracorporeal circulation was reinstituted in an antegrade fashion trough the IA or the side-branch of the graft. The rest of the procedure was carried out as usual. After protamine administration, the IA interposition graft was cut and oversewn with a double 5–0 polypropylene running suture.
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Fig. 1. Innominate artery cannulation with a graft interposition. AA: Ascending Aorta; IV: Innominate Vein; IA: Innominate Artery; IG: Interposition Graft.
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Fig. 2. Innominate artery direct cannulation. AA: Ascending Aorta; IV: Innominate Vein; IA: Innominate Artery; Ac: Arterial cannula.
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Standard monitoring included right and left radial arterial pressure lines, nasopharyngeal and rectal temperatures, transoesophageal echocardiography and regional oxygen saturation in the bilateral frontal lobes by means of a near-infrared spectroscopy (NIRS) for patients requiring ACP.
The operative procedures and perfusion data are depicted in Tables 2 and 3
, respectively.
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3. Results
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Hospital mortality was 3.6% (2/55). Causes of death were low cardiac output in both cases. No permanent neurologic dysfunction (PND) (stroke, coma) occurred in our series, and only one patient (1.8%) presented transient neurologic dysfunction (TND) with complete resolution before discharge. Pulmonary complications requiring a mechanical ventilatory support longer than 3 days occurred in five patients (9.1%), postoperative myocardial infarction in two patients (3.6%) and renal failure requiring temporary haemodialysis in one patient (1.8%). Mean postoperative drain blood production in the first 48 h was 690 ± 430 (range 200–1950). No rethoracotomy for bleeding was required. Mean postoperative hospital stay was 9 ± 4 days (range 3–29).
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4. Comment
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Brain complications represent a major concern during aortic surgery. It has been suggested that PNDs result from embolization of the brain and TNDs from inadequate methods of brain protection [6]. Therefore, in the last decade, the usage of ACP together with the selection of central cannulation sites such as the ascending aorta and the axillary artery by reducing the brain embolic risk have resulted in improved hospital mortality and neurologic outcome in patients undergoing surgery of the thoracic aorta [7–11].
In 2004, we started to cannulate the IA for CPB and ACP perfusion (when required) in selected patients undergoing thoracic aorta procedures.
The IA cannulation is associated with several advantages; most of them are similar to those obtained with RAA cannulation. These include
- (1) avoidance of retrograde perfusion of the thoracoabdominal aorta with reduced risk of brain embolism and organ malperfusion in patients with acute dissection;
- (2) facilitated brain perfusion during the circulatory arrest in aortic arch procedures requiring only one cannula (instead of two) for bi-hemispheric perfusion and no adjunctive cannula for unilateral brain perfusion;
- (3) IA cannulation, better than RAA cannulation, allows the surgeon to perform the whole procedure only through a standard sternotomy without the need for adjunctive incisions which may be complicated by infections, brachial plexus injuries or vascular compromise [12];
- (4) the IA cannulation site is always under the surgeon's eyes with reduced risk of annoying complications such as blood loss in the operative field and/or kinking of the cannulas.
In our experience, it was always easy and fast to prepare the IA even in obese patients who often make difficult the RAA preparation. The IA cannulation was always safely performed with no complications such as dissection, rupture or haematoma of the artery.
The risk of right hemisphere embolization seems not be increased by the IA cannulation. Indeed, in our experience with 55 patients, no PND occurred. To reduce the brain embolic risk, a careful evaluation of the IA arterial wall should always be performed by means of manual palpation, CT and/or epiaortic scan. The length of the IA was always sufficient to perform a safe cannulation 4–5 cm distal from the origin of the vessel where the likelihood of potentially dislodging the material is supposed to be lower.
In three cases (two acute dissections and one degenerative aneurysm), the IA was directly cannulated without a graft interposition. The procedure was even more simplified. For a safe direct cannulation, we believe, it is important to have both an adequate IA size and to use a side-holes cannula to avoid injuries to the arterial posterior wall.
Complex aortic arch procedures such as complete aortic arch replacement with the separated graft technique are not complicated but rather simplified by using the IA cannulation. For these cases, we duplicate the arterial line by means of a Y connector. One line is destined to the IA for both CPB institution and right hemisphere perfusion during the circulatory arrest. The second arterial line is connected to the forth branch of the vascular graft and opened to restart antegrade perfusion of the lower body as soon as the distal anastomosis and the left subclavian artery anastomosis have been completed [13].
However, the IA cannulation presents some disadvantages and contraindications.
Differently from the RAA, it cannot be performed for CPB institution before re-sternotomy in redo patients. Acute dissections, clearly extending distal into the IA, and calcifications of the IA should contraindicate its cannulation for the high risk of right brain embolism and malperfusion.
In conclusion, we believe the IA cannulation can be performed with a simple, fast and safe technique. Our results in terms of hospital mortality and neurologic outcome were encouraging. We consider the IA cannulation as a valid option for CPB and ACP institution, and we prefer it to the RAA in all patients undergoing aortic surgery except for those presenting calcifications or dissection of the IA.
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Abstract
1. Introduction
