Direct Innominate Artery Cannulation Research Articles

Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection

Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula. Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality. Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen. Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Innominate artery patency after direct cannulation in neonates.

ObjectiveThe study objective was to determine the short-term incidence of innominate artery stenosis for neonates who underwent direct innominate artery cannulation during the Norwood procedure.MethodsThis is a retrospective, single-institution review of 92 patients who underwent the Norwood procedure with direct innominate artery cannulation from 2006 to 2017. The primary outcome was angiographic evidence of patency at pre-Glenn cardiac catheterization. Patient characteristics, intraoperative surgical and hemodynamic measurements, and postoperative neurologic findings were recorded.ResultsAt a median age of 5.0 days, 92 neonates underwent the Norwood procedure with direct innominate artery cannulation. These patients underwent cardiac catheterization at a median of 3.0 months after the index operation. In 5 of 92 patients with catheterization images available for review, there was angiographic evidence of mild innominate artery stenosis, and none had moderate or severe stenosis. Review of follow-up records did not reveal evidence of clinically significant stenosis or innominate artery reintervention.ConclusionsIn neonates undergoing the Norwood procedure with direct innominate cannulation, innominate artery stenosis was uncommon and clinically significant stenosis did not occur.

Direct Innominate Artery Cannulation versus Side Graft for Selective Antegrade Cerebral Perfusion during Aortic Hemiarch Replacement.

Background Selective antegrade cerebral perfusion (SACP) has become our preferred method for cerebral protection during open arch cases. While the initial approach involved sewing a graft to the innominate artery as the arterial cannulation site, our access strategy has since evolved to central aortic cannulation with use of a percutaneous cannula in the innominate for SACP. We hypothesized that SACP delivered via direct innominate cannulation using a 12- or 14-Fr cannula results in equivalent outcomes to cases utilizing a side graft. Methods This was a single-center, retrospective analysis of 211 adult patients who underwent elective hemiarch replacement using hypothermic circulatory arrest with SACP via the innominate artery between 2012 and 2020. Urgent and emergent cases were excluded. Results A side graft sutured to the innominate was utilized in 81% ( n = 171) of patients, while direct innominate artery cannulation was performed in 19% ( n = 40) of patients. Baseline patient characteristics were similar between groups aside from a higher baseline creatinine in the direct cannulation group (1.3 vs. 0.9, p = 0.032). Patients undergoing direct cannulation demonstrated shorter cardiopulmonary bypass time (132.7 vs. 154.9 minutes, p = 0.020) and shorter circulatory arrest time (8.1 vs. 10.9 minutes, p = 0.004). Nadir bladder temperature did not significantly differ between groups (27.2°C for side graft vs. 27.6°C for direct cannulation, p = 0.088). There were no significant differences in postoperative outcomes. Conclusion Direct cannulation of the innominate artery with a 12- or 14-Fr cannula for SACP during hemiarch replacement is a safe alternative to using a sutured side graft. While cardiopulmonary bypass and circulatory arrest times appear improved, this is likely attributable to accumulation of experience and proficiency in technique. However, direct innominate artery cannulation may facilitate quicker completion of these procedures by eliminating the time necessary to suture a graft to the innominate artery.

The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection

BackgroundDirect cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection.MethodsA multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis.ResultsSeventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%).ConclusionsThis study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

Direct Arterial Cannulation Allows Easy and Safe Continuous Selective Cerebral Perfusion During Repair of Interrupted Aortic Arch Even for Low Birth Weight Neonates.

To review the outcomes of direct innominate artery cannulation for continuous cerebral perfusion used for repair of interrupted aortic arch (IAA) in a consecutive cohort of neonates regardless of weight. Between September 1999 and April 2016, forty-four children with IAA (18 type A and 26 type B) underwent repair using continuous, hypothermic (18°C) low-flow cerebral perfusion via direct innominate artery cannulation. Associated cardiac lesions were truncus arteriosus (TA; 5), ventricular septal defect (VSD; 30), transposition of the great arteries (TGA; 1), unbalanced atrioventricular septal defect (1), double-inlet left ventricle (1), double-outlet right ventricle (3), and aortopulmonary window (APW; 5). Truncus arteriosus, single VSD, TGA, and APW were corrected while the other patients were palliated. Age at the time of surgery was 7 days (4-120 days) and weight 3.1 kg (2.1-5.8 kg). Selective cerebral perfusion was maintained in all patients. During the selective cerebral perfusion, perfusion flow rate was maintained at 30 mL/kg/min. Aortic cross-clamp time, low-flow, and total cardiopulmonary bypass time were 63 (40-116), 28 (17-41), and 108 (80-217) minutes, respectively. There were no deaths nor clinical evidence of neurological injury. Postoperative ventilation time, length of intensive care unit, and hospital stay were 3 (2-14), 5 (3-21), and 13 (6-27) days, respectively. Follow-up, complete at 84 months (24-221), revealed no late clinically evident neurologic sequelae nor innominate artery complications. Direct innominate arterial cannulation with continuous selective cerebral perfusion can be safely applied for repair of IAA even in low birth weight neonates. It is technically simple and associated with excellent clinical outcomes.

No-Air Direct Innominate Artery Cannulation Technique for Aortic Arch Surgery

No-Air Direct Innominate Artery Cannulation Technique for Aortic Arch Surgery

Direct Innominate Artery Cannulation as a Sole Systemic and Cerebral Perfusion Technique in Aortic Surgery

Arterial cannulation is often challenging in thoracic aortic surgery due to the location of the surgery and need for cerebral protection during periods of circulatory arrest. Cannulation sites including the ascending and descending aorta, axillary, carotid and femoral arteries have limitations and are associated with complications due to their proximity to surrounding structures. Therefore, the innominate artery can be used by either direct cannulation or indirect cannulation via a graft as an alternative site. We present a technique of sole direct innominate artery cannulation that is able to provide both systemic and selective antegrade cerebral perfusion during aortic surgery.

Direct Innominate Artery Cannulation as Sole Visceral and Cerebral Perfusion Technique in Thoracic Aortic Surgery

Direct Innominate Artery Cannulation as Sole Visceral and Cerebral Perfusion Technique in Thoracic Aortic Surgery

Direct innominate artery cannulation: An alternate technique for antegrade cerebral perfusion during aortic hemiarch reconstruction

ObjectiveWe describe an alternate technique for establishing antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest via direct, central cannulation of the innominate artery. MethodsFrom 2009 to 2015, 100 elective hemiarch reconstructions for proximal aortic aneurysms were performed under moderate hypothermic circulatory arrest (MHCA). Cerebral perfusion was instituted with ACP via direct cannulation of the innominate artery. ResultsMean patient age was 63 ± 13 years (72 men; 72%). Mean MHCA temperature was 27.3°C ± 1.0°C (median, 28°C). Mean ACP time was 17 ± 4 minutes and mean crossclamp time was 134 ± 42 minutes. Proximal reconstruction included root replacement with composite valved graft (n = 47), valve sparing root reimplantation (n = 16), and aortic valve replacement (n = 19). In-hospital 30-day mortality (n = 1; 1%), stroke (1; 1%), reversible ischemic neurologic deficit (n = 1; 1%), coma (n = 0), and renal failure (n = 1; 1%) rates were low. There was no incidence of injury or dissection of the innominate artery. ConclusionsDirect, central innominate artery cannulation for ACP yields excellent outcomes. This technique is safe, provides excellent cerebral protection during circulatory arrest and simplifies the circulatory management strategy for elective ascending aortic and hemiarch reconstruction.

Single-stage repair of aortic arch and associated cardiac defects with antegrade cerebral perfusion using direct innominate artery cannulation in neonates and infants

Background Selective cerebral perfusion avoids deep hypothermic circulatory arrest in single-stage repair of the aortic arch and associated cardiac defects in neonates and infants. Direct innominate artery cannulation is accepted as a safe technique to obtain this objective.

Moderate Versus Deep Hypothermic Circulatory Arrest for Elective Aortic Transverse Hemiarch Reconstruction

Deep hypothermic circulatory arrest (DHCA) with retrograde cerebral perfusion (DHCA group) has traditionally been the cerebral protection strategy during transverse hemiarch aortic reconstruction. Recently, we have adopted moderate hypothermic (≥ 25 °C) circulatory arrest (MHCA) with antegrade cerebral perfusion (MHCA group). We compared the outcomes for these two circulatory arrest management strategies. From 2008 to 2012, in a concurrent series of 376 patients (DHCA, 301; MHCA, 75) undergoing transverse hemiarch for aortic aneurysm disease, incidences of concomitant root replacement (44% vs 47%, p = 0.8), and aortic valve replacement (29% vs 21%, p = 0.3) were similar, although atherosclerotic aneurysm pathology was present in patients in the MHCA group (71% vs 33%, p < 0.01). Antegrade cerebral perfusion was established via axillary artery or direct innominate artery cannulation. A database was prospectively maintained. MHCA group patients were older (66 ± 11 vs 60 ± 14 years; p < 0.01). Other demographics were similar. Aortic cross-clamp (128 ± 46 vs 163 ± 57 minutes, p < 0.01) and cardiopulmonary bypass (167 ± 49 vs 222 ± 61 minutes, p < 0.01) times were lower in the MHCA group. Transfusion requirements were significantly reduced with MHCA (38% vs 61%, p < 0.01), especially use of fresh frozen plasma and cryoprecipitate. Direct innominate artery cannulation did not result in any vascular or neurologic complication. Postoperative outcomes were similar. In-hospital and 30-day mortality was 1% in both groups. Stroke (0% vs 2%) and hemodialysis rates (0% vs 1%) were also similar. MHCA with antegrade cerebral perfusion yields excellent and equivalent outcomes to DHCA for elective aortic hemiarch reconstruction. MHCA significantly improves intraoperative times and, importantly, reduces transfusion requirements compared with DHCA with a retrograde cerebral perfusion strategy.

Direct innominate artery cannulation for selective antegrade cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery

To demonstrate a novel, reproducible, and effective method of direct innominate artery cannulation using a 14 F pediatric venous cannula to establish antegrade cerebral protection (ACP) in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement. We reviewed prospectively gathered data on all patients who had undergone replacement of the ascending aorta or hemiarch with an open distal anastomosis using deep hypothermic circulatory arrest and direct innominate artery cannulation with a 14 F pediatric venous cannula at our institution. After central cannulation and cooling to 25 °C to 28 °C, all patients had ACP initiated by way of a direct innominate cannula placed over a guidewire. Fifty patients underwent direct innominate artery cannulation with our technique from 2010 to 2012. The operative mortality was 2% (n = 1), and the rates of neurologic morbidity were acceptable and similar to those with other methods of ACP delivery: stroke (2%, n = 1), seizure (0%, n = 0), and delirium (18%, n = 9). The mean operative time was 31 ± 9, 19 ± 5, 100 ± 39, 141 ± 39, and 259 ± 63 minutes for cooling, circulatory arrest, crossclamp, cardiopulmonary bypass, and total operative time, respectively. No local or arterial complications were observed. Direct cannulation of the innominate artery using a 14 F pediatric venous cannula is a simple, reproducible, safe, and effective technique for establishing ACP in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement. This technique avoids the additional time and potential local complications associated with other established methods for delivering ACP, such as axillary cannulation.

Direct Innominate Artery Cannulation in Surgery for Annuloaortic Ectasia

The selection of the ideal cannulation site is still one of the major concerns in ascending aortic surgery. In the last decade, many surgeons have chosen to utilize antegrade cerebral perfusion in hypothermic circulatory arrest. In this study, we aimed to evaluate arterial cannulation techniques in patients who underwent root replacement for annuloaortic ectasia. Between 2005 and 2012, a total of 69 patients with a diagnosis of annuloaortic ectasia underwent aortic root replacement with femoral artery, axillary artery, and direct innominate artery cannulation (IAC). Patients demographic, operative, and postoperative data were collected prospectively and analyzed. A total of 69 patients were investigated. Their ages varied from 13 to 78 (mean age was 54.25 ± 15.69) and 48 patients were male (69.5%). Mean aortic diameter was 5.65 ± 1.58 cm (min: 4.5 cm to max: 7.8 cm) by computerized tomography. The procedures included modified Bentall operation in 61 patients, and Cabrol operation in eight patients. In hospital, the mortality rate was 1.85%, and a 30-day mortality rate was 3.7% in the IAC group and 6.6% in patients who underwent femoral and axillary artery cannulation. Temporary cognitive dysfunction and stroke rate were similar between groups. Innominate cannulation is associated with low morbidity and mortality in patients who underwent ascending aorta surgery.

Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction

The deep hypothermic circulatory arrest (DHCA) technique has been used in aortic arch and isthmus hypoplasia for many years. However, with the demonstration of the deleterious effects of prolonged DHCA, selective cerebral perfusion (SCP) has started to be used in aortic arch repair. For SCP, perfusion via the innominate artery route is generally preferred (either direct innominate artery cannulation or re-routing of the cannula in the aorta is used). Herein, we describe our technique and the result of arch reconstruction in combination with selective cerebral and myocardial perfusion (SCMP) and short-term total circulatory arrest (TCA) (5-10 min) through ascending aortic cannulation. Thirty-seven cases with aortic arch and isthmus hypoplasia accompanying cardiac defects were operated on with SCMP and short TCA in Baskent University Istanbul Research and Training Hospital between January 2007 and Sep 2012. There were 17 cases with ventricular septal defect (VSD)-coarctation with aortic arch hypoplasia (CoAAH), 4 cases of transposition of the great arteries-VSD-CoAAH, 4 cases of Taussing Bing Anomaly-CoAAH, 2 cases complete atrioventricular canal defect-CoAAH, 3 cases single ventricle-CoAAH, 3 cases of type A interruption-VSD, 2 subvalvular aortic stenosis-CoAAH and 2 cases of isolated CoAAH. The aorta was cannulated in the middle of the ascending aorta in all cases. The cross-clamp was applied to the aortic arch distal to either the innominate artery or the left carotid artery. In addition, a side-biting clamp was applied to the descending aorta. The aorta between these two clamps was reconstructed with gluteraldehyde-treated autogeneous pericardium, using SCMP. The proximal arch and distal ascending aorta reconstructions were carried out under short TCA. The mean age of the patients was 2.5 ± 2 months. The mean cardiopulmonary bypass and cross-clamp times were 144 ± 58 and 43 ± 27 minutes, respectively. The mean SCMP and descending aorta ischemia times were 22.6 ± 4.8 and 27 ± 6.3 minutes, respectively. Mean TCA time was 7.6 ± 2.1 minutes (min: 4, max 10 min). The mean in-hospital stay time was 8.6 ± 1.9 days. None of the cases operated with this technique had neurological defects. The mortality rate was 2.7% (1 patient). SCMP with aortic cannulation and short TCA (under 10 minutes) in aortic reconstruction is safe and practical in this high-risk patient group.

Direct Innominate Artery Cannulation for Antegrade Cerebral Perfusion in Neonates Undergoing Arch Reconstruction

Antegrade cerebral perfusion (ACP) is performed in neonates either by direct cannulation (DC) or indirect cannulation (IC) of the innominate artery. IC is achieved by a graft sutured to the innominate artery or advancement of a cannula through the ascending aorta into the innominate artery, whereas DC is performed by directly cannulating the innominate artery. These techniques may be limited by technical problems that can compromise perfusion. The purpose of the present study was to evaluate the flow measurements and safety of DC when compared with IC. This was a retrospective chart review of consecutive neonates who underwent ACP from January 2007 to December 2010. Patient characteristics, surgical and hemodynamic measurements, and postoperative neurologic findings were recorded. Seventy neonates underwent ACP during the study period (46 using DC and 24 using IC). The groups were similar in age and weight. Operative variables were similar regarding cardiopulmonary bypass (CPB), cross-clamp times, maximal flow at full CPB, minimal temperature, ACP time, flow and flow index, and upper extremity blood pressure and proximal cannula pressure during ACP. There was a significantly higher flow index at full CPB in the DC group (217 ± 40 mL/kg/min versus 190 ± 46 mL/kg/min; p = 0.013), which correlated with higher proximal cannula pressures at full CPB (172 ± 27 mm Hg versus 158 ± 26 mm Hg; p = 0.04). Sixty-two of the 65 survivors (95%) had normal neurologic evaluations on discharge. ACP using DC is comparable to that using IC, with appropriate pressures in the proximal aortic line at full CPB and adequate upper extremity pressures during ACP, reflecting suitable flows in the cerebral circulation.

Safe Innominate Artery Cannulation for Cardiopulmonary Bypass in Neonates

To reduce the neurological complications of deep hypothermic circulatory arrest, continuous cerebral perfusion was introduced, either by direct innominate artery cannulation or by a tubular prosthesis. This second option, used in our clinical experience, has been extended to applications other than aortic arch reconstruction, to facilitate cardiopulmonary bypass in small neonates (< 3.0 kg) with complex congenital heart defects, and to facilitate postoperative extracorporeal membrane oxygenation.

Direct Innominate Artery Cannulation in Acute Type A Dissection and Severe Thoracic Aortic Atheroma

ACUTE TYPE A aortic dissection is a surgical emergency.1 Integrated perioperative management is associated with improved clinical outcome, despite aortic arch repair with deep hypothermic circulatory arrest (DHCA).2,3 Femoral arterial cannulation is safe for all phases of operative repair (before aortic arch repair; after aortic arch repair), with a 2.5% incidence of malperfusion events.4 Although the femoral artery is the authors’ standard site for arterial cannulation in this setting, a case of acute type A dissection in a severely atheromatous aorta is reported that prompted a search for an alternative arterial cannulation site because of concerns about cerebral atheroembolization.

Cerebral malperfusion in acute type A dissection: Direct innominate artery cannulation

Cerebral malperfusion in acute type A dissection: Direct innominate artery cannulation