Axillary Artery Cannulation Research Articles

Deltoido-pectoralis approach to axillary vessels for full-flow cardiopulmonary bypass

Axillary artery has been proposed as a safe and effective alternative for arterial cannulation in surgical procedures involving ascending aorta and/or aortic arch, and is nowadays the site of choice in many centres. Advantages of axillary artery cannulation include antegrade flow and the possibility of selective mono-hemispherical brain perfusion during circulatory arrest. Experiences with the axillary vein cannulation, however, are scarce. Here we report our preliminary experience with axillo-axillary cardiopulmonary bypass, through both axillary artery and vein cannulation (using echo-guided Seldinger technique) at deltoido-pectoralis groove. We have used such an approach in 5 cases of redo surgery on ascending aorta and we have not had any inconvenience during cardiopulmonary bypass. Full flow was maintained in all patients (in 2 with vacuum assisted drainage) including 2 cases with deep hypothermic circulatory arrest. In conclusion such an approach seems to be feasible and effective and can be safely performed providing that accurate TE echo monitoring is provided.

Axillary Artery Cannulation for Cardiopulmonary Bypass during Surgery on the Ascending Aorta and Arch

Performing axillary artery cannulation, during cardiopulmonary bypass in patients with an atherosclerotic ascending aorta or acute dissection of the ascending aorta and arch, is of growing interest. Our aim is to present our experience, to describe the surgical technique, and to demonstrate the sufficient cerebral and total body perfusion through axillary artery cannulation. Twenty-two patients (17 male, five female) underwent surgical treatment with the axillary technique. The log euro SCORE ranged from 6.77% to 70% (mean 28.28). Nine of these patients underwent elective procedure. Eight underwent aortic surgery for pathologies of the aorta and in one patient we performed combined aortic valve replacement and coronary artery bypass grafting. Thirteen patients underwent emergency operation because of acute dissection of the aorta. Twelve of these patients had a type A dissection (according to Stanford classification) and one patient had a type B aortic dissection. The majority of complications were associated with ruptured dissection of the thoracoabdominal aorta and acute dissection of ascending aorta. Despite preoperative disease states that placed our patients at high risk of stroke and visceral end-organ injury, no clinically demonstrable permanent postoperative deficits were observed. Our patients had no neurological dysfunction, stroke, or other complications. Antegrade cerebral perfusion is of paramount importance in cases of aortic atherosclerosis or aortic dissection. The axillary artery provides an excellent site for safe antegrade perfusion, which may play a role in preventing stroke.

Open distal anastomosis in aortic root replacement using axillary cannulation and moderate hypothermia

Recent advance in surgical technique facilitates more aggressive approaches for thoracic aortic diseases. We sought to address the outcomes of our strategy of open distal anastomosis with aortic root replacement using axillary cannulation and moderate hypothermia. A retrospective review of 228 patients who underwent aortic root replacement between July 2004 and December 2007 was performed. Axillary artery cannulation was successful in 98% of the attempted cases and resulted in no adverse events in 97%. The axillary artery was the site of arterial cannulation in 89% of the cases, among which 136 patients (60% of the cases) underwent an open distal anastomosis, consisting of the cohort of interest. Median age of the patients was 60 years (ranging from 16 to 89 years) with 79% being male. The principal diagnosis for the operation included aneurysmal disease without aortic dissection (78%), type A aortic dissection with or without aneurysm (12%), and endocarditis (5.9%). Performed operations were modified Bentall operation (53% of the cohort), valve-sparing aortic root replacement (26%), and replacement with a homograft (20%). Hemiarch replacement was added in 43%. Mean +/- standard deviation of the lowest temperature was 27 degrees C +/-2.6 degrees C. There were 5 deaths (mortality 3.7%). A total of 16 patients (12%) had major complications. Open distal anastomosis at the time of aortic root replacement can safely be performed with axillary artery cannulation and moderate hypothermia. Axillary cannulation provides a reliable route of antegrade cerebral perfusion and enables the complex procedure to be performed without deep hypothermic circulatory arrest.

Invited Commentary

The authors describe an operative experience of 181 patients with prior sternotomy who underwent mitral valve operations through a right lateral 4- to 8-cm minithoracotomy [1Seeburger J. Borger M.A. Falk V. et al.Minimal invasive mitral valve surgery after previous sternotomy: experience in 181 patients.Ann Thorac Surg. 2009; 87: 709-714Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar]. The cardiopulmonary bypass support technique used femoral vessel access and retrograde arterial perfusion. In more than 75% of these patients, the mitral operation was done without cross-clamping and with the technique of ventricular fibrillation. The authors report relatively good results—a 30-day mortality of 6.6% and a stroke incidence of 3.8%. Although it is difficult to have a comparable control group, as described in their limitations section, the authors have achieved excellent results in this difficult cohort of patients. Several good points mentioned by the authors should be reemphasized. The importance of a preoperative chest computed tomography scan to evaluate the anatomy and aid in approach planning should not be underestimated. The presence of right pleural disease (due to prior resection or pleurodesis) is a serious contraindication and should lead the surgeon to evaluate a left-sided approach. Finally, this large series reconfirms the efficacy and safety of “ignoring” a patent left interior mammary artery graft and mitigates its presence by the strategy of additional core cooling. I am disappointed, however, that in this large series, central aortic or right axillary arterial cannulation was never used; each approach has the advantage of antegrade aortic perfusion. Although this is a relatively young cohort with presumably less atherosclerotic aortic burden and at low risk for complications from retrograde perfusion, data from our institution and the Cleveland Clinic demonstrate a lower incidence of neurologic complications when overall antegrade perfusion strategy is used. These alternative cannulation techniques are important to have in one's armamentarium; central arterial perfusion provides a good option when femoral or iliac occlusive disease is present. The authors stated that the femoral system was evaluated with preoperative computed tomography, but did not state what happened to these patients when such disease was encountered. The authors are to be congratulated on this fines series. By applying the basic surgical principals of good vision and approach through a relatively virgin operative field, they have achieved excellent results for this cohort of high-risk reoperative patients. Minimally Invasive Mitral Valve Surgery After Previous Sternotomy: Experience in 181 PatientsThe Annals of Thoracic SurgeryVol. 87Issue 3PreviewThis study evaluated the results for minimally invasive mitral valve (MV) surgery in patients who had undergone previous cardiac operations through a sternotomy. Full-Text PDF

Liberal use of axillary artery cannulation for aortic and complex cardiac surgery

Liberal use of axillary artery cannulation for aortic and complex cardiac surgery

Early and late outcome of 527 consecutive patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock (PCS)

Aims: PCS occurs in 1–2% of cardiac surgery patients. Hospital and long-term results of 527 consecutive patients receiving ECMO implantation were evaluated. Methods: Between 05/96 and 05/08 527 of 40.538 pts (1.3%) undergoing cardiac surgery (37.1% elective, 24.4% urgent, 38.5 emergency) received perioperative ECMO support. Procedures were isolated CABG (32.6%), CABG+valve surgery (19.3%), valve surgery (38.1%), thoracic organ transplantation (6.4%) and others (3.8%). Fourty-four preoperative, 28 intraoperative and 42 postoperative risk factors were evaluated by uni- und multivariate logistic regression analysis to identify risk factors for early mortality. Cumulative survival was estimated by Kaplan-Meier analysis. Mean follow-up was 2.9y (0.1–11.4y). Results: Age was 61.3y, 73.0% were male, ejection fraction was 44.2±17.3%. ECMO implantation was performed through thoracic (56.7%) or extrathoracic (42.3%) cannulation using femoral or axillary arterial and femoral venous cannulation. Additional IABP support was employed in 74.3%. Mean drainage loss was 4.4 liter after 48h. 52.7% were successfully weaned from ECMO after mean 86h and 24.4% were discharged from hospital after 41±25d. Neurological complications occurred in 12.3%. Hospital mortality was 75.6%. Risk factors for hospital mortality were emergency indication, preoperative cardiogenic shock, EF 70y and diabetes were none. Cumulative survival was 20.2±2.9% after 6 months, 18.7±2.7% after one and 16.3±3.3% after five years. Conclusion: Temporary ECMO support it is an acceptable option for patients with PCS that otherwise would die. However due to high morbidity and mortality individual indication has to be made on the specific risk profile.

Left axillary arterial perfusion for cerebrospinal protection in proximal descending aortic aneurysm

A 73-year-old man presented with DeBakey type IIIa chronic aortic dissection. The aneurysm of the descending aorta was replaced using an open proximal technique with hypothermic circulatory arrest. For cerebrospinal protection, the left axillary artery was cannulated, which perfuses the vertebral artery and affects the Willis arterial circle, the anterior spinal artery, and the collateral blood supply to the spinal cord. Cannulation of the left axillary artery was a safe and effective surgical option for antegrade cerebral perfusion and spinal protection.

Axillary Artery Perfusion in Acute Type A Aortic Dissection Repair

We evaluated our experience with axillary artery perfusion technique in acute type A aortic dissection repair. Between September 2000 and July 2006, 41 consecutive patients with acute type A aortic dissection underwent surgical repair. In 35 of 41 patients (85.4%), arterial perfusion was performed through right axillary artery and in the remaining six patients (14.6%), arterial perfusion site was femoral artery. Indication for femoral artery perfusion was cardiac arrest and ongoing cardiopulmonary resuscitation in one and pulselessness of right upper limb in five patients. Mean age was 54.9 +/- 15.3 (16 to 90 years) and 28 were male. Unilateral antegrade cerebral perfusion (perfusate temperature 22 to 25 degrees C) through axillary artery was performed in all axillary artery perfused patients and in three patients who had femoral artery perfusion. Five patients died postoperatively (hospital mortality 12.2%). All of them had evidence of single or multiple organ malperfusion preoperatively. We did not experience any new transient or permanent neurologic deficit after the procedure in the unilateral antegrade cerebral perfusion patients. Complications related to axillary artery cannulation were observed in two patients (5.3%). One patient with femoral artery cannulation experienced femoral arterial thrombosis, postoperatively. Right axillary artery cannulation for repair of acute type A aortic dissection is a simple and safe procedure. In the case of pulselessness of right upper limb, femoral artery is still the choice of cannulation site.

Evolving arch surgery using integrated antegrade selective cerebral perfusion: Impact of axillary artery perfusion

The study objective was to determine the impact of integrated antegrade selective cerebral perfusion with right axillary artery perfusion during arch surgery. All surgeries were performed through a median sternotomy. Direct cannulation of the right axillary artery in the axilla was used for cardiopulmonary bypass and antegrade selective cerebral perfusion under hypothermia. In addition, ascending aortic or femoral artery perfusion was used. The clinical records of 531 patients (median age, 72 years) between 1999 and 2006 were reviewed, of whom 137 patients (25.8%) underwent emergency surgery. There were 164 dissecting and 367 nondissecting aortic lesions. The surgeries included total arch replacement in 431 patients, partial arch replacement in 9 patients, and hemiarch replacement in 91 patients. The early mortality rate was 4.0% (2.3% of 30-day mortality and 1.7% of in-hospital mortality). The incidence of permanent neurologic dysfunction was 2.9% in all (3.3% in total arch replacement and 1.0% in hemiarch or partial arch replacement). The incidence of temporary dysfunction was 9.9% in all (10.6% in total arch replacement and 7.0% in hemiarch or partial arch replacement). Multivariate analysis demonstrated that the risk factors for early mortality were chronic renal failure, ruptured nondissecting aneurysm, and prolonged surgery. The midterm survival was 87.2% +/- 1.7% at 3 years and 80.5% +/- 2.6% at 5 years. Right axillary artery perfusion is an advantageous adjunct to cardiopulmonary bypass and antegrade selective cerebral perfusion in arch surgery.

Axillary Cannulation Significantly Improves Survival and Neurologic Outcome After Atherosclerotic Aneurysm Repair of the Aortic Root and Ascending Aorta

The impact of axillary artery cannulation (AXC) on survival and neurologic outcome after operation for ascending aortic disease was retrospectively evaluated. We reviewed 869 patients with ascending aorta/root repairs (1995 to 2005), principally for atherosclerotic and degenerative aneurysms and chronic and acute type A dissections. Arterial cannulation was through the ascending aorta (AAC) in 157 patients, the femoral artery (FAC) in 261, and the right axillary artery (AXC) in 451. Patients cannulated at different sites were compared for preoperative comorbidities and outcomes (mortality and stroke) for each cause. Of the 122 patients with atherosclerotic aneurysms, 66 with right AXC had significantly better outcomes (p = 0.02): 64 of 66 survived vs 24 of 26 with FAC and 27 with 30 of AAC; no strokes occurred (vs 2 of 26 with FAC and 4 of 30 with AAC). No significant advantage for AXC was found with ascending aortic operation in 495 degenerative aneurysms, 106 chronic, or 65 acute type A dissections, 41 patients with endocarditis, or in 18 with aneurysms of other causes; AXC was associated with a significantly better outcome (p = 0.05) in the 869 patients taken together. AXC resulted in superior survival and neurologic outcome in patients with atherosclerotic aneurysms and a marginally better outcome than with cannulation at other sites during proximal aortic procedures for all causes. This study supports AXC in patients with atherosclerotic disease who require complex cardiothoracic operations and in patients requiring proximal aortic intervention regardless of cause.

Rapid and safe establishment of cardiopulmonary bypass in repair of acute aortic dissection: improved results with double cannulation

There is no agreement at present as to which is the optimal site for artery cannulation for cardiopulmonary bypass in repair of acute aortic dissection (AAD). We have employed right axillary artery cannulation (RAAC) in combination with femoral artery cannulation to overcome the drawbacks of single cannulation. From January 2000 to August 2006, 88 patients underwent emergency surgical repair of the aortic arch (mean age 65+/-13 years, 37 men) for AAD. All operations were performed under hypothermic circulatory arrest with antegrade selective cerebral perfusion. Preoperatively, nine patients were in shock and 18 patients showed malperfusion. The average duration of circulatory arrest was 52+/-17 min and that of myocardial ischemia was 135+/-53 min. Total aortic arch replacement was done in 47 patients and hemiarch aortic replacement in 41. The hospital mortality rate was 2.3% (2 of 88); the fatal cases were among those who were in shock preoperatively. The perioperative stroke rate was 5.7% (5 of 88). The hospital mortality rate of the 25 patients with preoperative malperfusion was 4.0% (1 of 25); the fatal case had coronary malperfusion. Our approach for AAD was associated with a low mortality even in patients with malperfusion.

Safety of Unilateral Antegrade Cerebral Perfusion at 22°C Systemic Hypothermia

The superiority of antegrade cerebral perfusion (ACP) in aortic surgery is widely accepted, but the sufficiency of unilateral cerebral perfusion and the optimal systemic temperature during the operation are still controversial. Thirty patients who underwent operation with unilateral ACP at a systemic temperature of 22 degrees C between January 2005 and September 2007 were included in this study. The mean age (+/-SD) of the patients was 58 +/- 11 years, and 21 (70%) of the patients were male. The indication for surgery was acute type A aortic dissection in 14 patients (47%), degenerative aortic aneurysm in 9 patients (30%), dissecting aortic aneurysm in 6 patients (20%), and intramural hematoma in 1 patient (3%). Supracoronary ascending aorta replacement was performed in 13 patients (43%). Eight patients (27%) underwent ascending aorta and hemiarch replacement. The Bentall procedure was performed with hemiarch replacement in 3 patients (10%). Three patients (10%) underwent total aortic arch replacement, and 2 patients (7%) underwent the Bentall procedure. The ascending aorta, aortic arch, and descending aorta were replaced in 1 patient (3%). Hospital mortality was limited to 1 patient (3.3%). A permanent or transient neurologic deficit was not detected in any of the survivors. The mean cardiopulmonary bypass, aortic cross-clamp, and ACP times were 144 +/- 40 minutes, 82 +/- 28 minutes, and 30 +/- 11 minutes, respectively. The mean mechanical ventilation time was 18 +/- 9 hours. The mean stay in the intensive care unit was 2.3 +/- 1.1 days, and the mean hospital stay was 12 +/- 6 days. Unilateral ACP with systemic hypothermia at 22 degrees C is safe and has satisfactory clinical results. Establishing ACP via cannulation of the right axillary artery is fast and simple. The presence of fewer cannulas in the operation field provides an operative condition as convenient as the deep hypothermic circulatory arrest technique.

Innominate artery cannulation

Innominate artery cannulation is indicated mainly for surgery which involves aortic root and aortic arch when pathology precludes standard cannulation of the ascending aorta. Thus, it can be used as the procedure of choice in cases of ascending aortic aneurysm, type A aortic dissection, porcelain aorta and reoperation for coronary or aortic surgery. It is performed through a standard median sternotomy, hence avoiding the complications of a second incision. It provides antegrade systemic and cerebral flow that is associated with improved distal organ perfusion and reduced rate of retrograde cerebral embolization compared to femoral arterial cannulation, Moreover, it eliminates potential complications from axillary artery cannulation, such as dissection, upper extremity malperfusion and brachial plexus injury. It is contraindicated in cases of excessive calcification and acute dissection clearly involving the innominate artery.

The combination of central aortic cannulation and no clamping technique in acute type a aortic dissection – results of 90 patients

Objective: Femoral artery cannulation is the customary cannulation site in acute type a-aortic dissection (AADA) with the risk for retrograde embolisation and malperfusion. Axillary artery cannulation becomes increasingly accepted by cardiac surgeons. Cannulation of the ascending aorta or the aortic arch is the routine approach for all cardiac surgeons, so why not in AADA?

Atherosclerotic aneurysm repair of the ascending aorta and aortic root: Does axillary cannulation improve neurological outcome?

Objective: Axillary artery cannulation (AxC) is increasingly being utilized for ascending aorta/root repair, but its impact on neurological outcome remains somewhat controversial. A retrospective evaluation of the influence of AxC on outcome after surgery for ascending aortic disease of different etiologies was undertaken.

Novel Technique for Aortic Arch Surgery Under Mild Hypothermia

We present our initial experience in 5 patients for open aortic arch repair with continuous antegrade perfusion of the brain and of the lower body by means of direct cannulation of the right axillary artery and of the descending aorta with a venous cannula (DLP 91037 cannula [Medtronic Inc, Minneapolis, MN]) for systemic perfusion under mild hypothermia (30 degrees C). This mode of perfusion allows safe open repair of the aortic arch, short aortic cross clamping, and CPB times associated to all the known advantages of the mild hypothermia; this technique could have the potential to be generally applicable in surgeries for aortic arch repairs after further evaluation.

Acute intraoperative aortic dissection following axillary artery cannulation

We describe a 75-year-old woman who underwent right axillary artery cannulation in preparation for reconstruction of the aortic arch and the proximal descending aorta for athesosclerotic aortic aneurysm via a 'clamshell' incision. As soon as cardiopulmonary bypass was established, the ascending aorta and the aortic arch was dissected. The innominate artery was dissected including one-third of its circumferance anteriorly. Arterial perfusion was stopped immediately and the left femoral artery was cannulated to resume CPB. We proceeded with replacement of the ascending aorta, the aortic arch and the proximal descending thoracic aorta with a Dacron branched aortic graft. The patient recovered uneventfully. Arterial blood pressure was equal bilaterally.

EComment: TEE- and guidewire-guided axillary artery cannulation. An option?

eComment: TEE- and guidewire-guided axillary artery cannulation. An option?

Innominate Artery Cannulation for Aortic Surgery

When disease involving the ascending aorta or aortic arch precludes ascending aortic cannulation, axillary artery cannulation is used for cardiopulmonary bypass. An additional incision and the relatively small caliber of the axillary artery are the drawbacks of this approach. Innominate artery cannulation using the same sternotomy wound is a simple and effective alternative.

Pseudoaneurysm of a saphenous bypass treated with covered endograft in the ascending aorta

Aneurysms and pseudoaneurysms complicating aorta–coronary bypasses with the saphenous vein are a rare but possibly underestimated complication. Riahi and associates1 reported the first case in 1975. We report the first case of a saphenous bypass pseudoaneurysm treated with a homemade endograft in the ascending aorta.