Carotid artery cannulation in aortic surgery: why not?

Abstract

Since the first use of cardiopulmonary bypass during replacement of the aortic arch in the early 1960s, the techniques of arterial cannulation have been highly variable. Yet, during several decades, the problem was considered as solved. The femoral artery was almost systematically used and it took almost 30 years to get aware that this technique could be harmful in some patients and the cause of severe complications, such as embolism and malperfusion, even rupture of the aorta, in particular in cases of acute dissection. It became obvious then that a satisfactory arterial cannulation should provide an antegrade flow to the whole aorta, and that it should allow possibly performing a proper cerebral protection during the time of arch exclusion and repair. Many solutions were proposed and described but not systematically adopted as they were either too complicated, or were associated with too many drawbacks. In 1995, Sabik et al. [1] proposed to use the right axillary artery. This approach had indeed many advantages and was obviously fulfilling most of the requirements of the surgical community. The technique was rapidly popularized and adopted by most groups dealing with aortic surgery, especially aortic arch replacement. But, as nothing is perfect in this small world, the use of this arterial site proved through many large experiences, to also have drawbacks and complications that could represent some disincentive for its systematic use. So, in 2006, Urbanski [2] proposed to use systematically the common carotid artery through a side graft and for both the whole cardiopulmonary bypass and the cerebral protection. In this paper of the MMCTS, Urbanski [3] perfectly describes the technical features of this mode of cannulation and perfusion. The text is clear, and well written; the video perfectly shows the surgical procedure and, quite interestingly, the necessary time to achieve it in ~15 min that, obviously, is less than for the axillary artery and no more than for the femoral artery in most patients. Moreover, the rationale for using this technique is appropriately developed and convincing enough. In particular, the drawbacks of the other modes of cannulation are well presented and discussed. One exception, though: I do not totally agree with the author’s criticism of the innominate artery cannulation. It is stated, indeed ‘it (the innominate artery) is frequently involved in aortic pathology, regardless if it is dissection or arteriosclerosis, and these pathological changes could be identified as predictors for increased neurological morbidity. Therefore, the IA cannulation is, in our opinion, suitable for cases with limited aortic repairs, e.g. hemi-arch replacements, in which the arch and proximal portions of the supra-aortic arteries are not pathologically changed’. The right common carotid artery being a branch of the innominate artery, the same comments should apply to this structure. In addition, even though the use of the innominate artery has been presented in recent years as a new and original technique, this is not the case. It is used by some groups for decades and I have used it as a routine mode of cannulation during the last 30 years in all types of cardiac and aortic surgery and not only for hemi-arch replacements. Another point of slight disagreement could be the fact that the author states having encountered no complications at all in more than 1000 cases. With all due respect to Paul Urbanski and to the excellent results reported here, it is somewhat difficult for me to agree that a vascular surgical approach, whatever its nature, would never provide any bleeding requiring reopening and drainage, small local (skin, muscles?) infection, small thrombus embolism or any complication of the kind. Why this technique that has been first described one decade ago is not more popular and used by most surgical groups? One reason could be unconscious and irrational. The carotid arteries provide the blood flow directly to the brain and the fear that any local complication occurring during the cannulation or the perfusion would lead to an immediate catastrophe might prevent many colleagues from using it. On the other hand, it is also possible that many groups remain faithful to their usual mode of cannulation, whatever its sophistication and drawbacks and are somewhat reluctant to try a new system. One may regret it as the technique as it is described in this paper seems rather promising and free from most of the disadvantages of the other available techniques. Indeed, this paper, associated with the various articles by Paul Urbanski and his group published in the cardiovascular literature in the last decade, demonstrates that the technique of using the common carotid arteries as a site of arterial cannulation during thoracic aortic surgery is sound, easy and safe, and provides excellent results in terms of whole body and selective cerebral perfusion. Undoubtedly, this technique should be more often used and have a much larger popularity worldwide.