EComment. Extended utilization of axillary cannulation as arterial access for cardiopulmonary bypass

Abstract

In cardiovascular practice today, the axillary artery is one of the best alternative cannulation sites in acute type A aortic dissection [1]. It provides potential benefits such as antegrade perfusion of the aorta, low risk of false lumen perfusion in aortic dissection, and the possibility of antegrade cerebral perfusion during aortic arch repair. Indications of axillary cannulation also includes porcelain aorta, ascending aorta and aortic arch aneurysm, coronary artery disease associated with severely atherosclerotic ascending aorta, extracorporeal membrane oxygenation support, and complex redo cardiac surgery such as aortic regurgitation after previous ascending aortic replacement and pseudo-aneurysm after Bentall operation. We read with great interest the article by Fong and associates [2], regarding liberal use of axillary artery cannulation for cardiopulmonary bypass in aortic and complex cardiac surgical patients. We mostly agree with their considerations. However, we believe that some aspects of the article require further comment. Direct or graft-interposed axillary cannulation still remains a controversial issue among the cardiovascular surgeons. We routinely prefer direct right axillary cannulation in acute type A aortic dissections in our institute [3]. In our practice, there were no major complications related to this cannulation technique. In our opinion, direct axillary cannulation is not more traumatic, is less time-consuming, and less haemorrhagic during the operation than the graft interposition. Axillary cannulation is not always free from risk. Complications related to axillary cannulation are becoming associated with increased use of this technique [4]. These include ipsilateral brachial plexus injury resulting in hand weakness and numbness, axillary artery thrombosis, lymphocele requiring aspiration, vascular compromise, compartment syndrome involving the forearm, postoperative bleeding or local wound infection. Acute intraoperative aortic dissection due to the arterial cannulation into the axillary artery is a rare and devastating complication [5]. It is believed to be due to an intimal flap occurring during cannula insertion. As a strategy to prevent these complications, the arterial cannula should not be advanced too much during the right axillary cannulation. Forced cannulation should also be absolutely avoided. It may cause arterial injury or obstruct the right carotid artery. In our experience, a 20F or 22F flexible cannula was gently advanced 3-4 cm into the axillary artery. In strategic planning for arterial cannulation, transoesophageal echocardiography (TEE) guidance is useful to ensure correct placement of the cannula. An angiograhic, TEE or ultrasound examination plays an important role in preoperative evaluation including aortic branch vessels Axillary cannulation is an attractive and useful approach with an extended utilization, and may be safely used in aortic surgery and complex cardiac procedures including redo surgery. Conflict of interest: none declared.