Peripheral Arterial Cannulation Research Articles

Direct Right Axillary Artery Cannulation as First Choice Strategy during Aortic Surgery Procedures: Results from a Single Experienced Surgical Centre

Objectives: Since early nineties axillary artery has been proposed as alternative to femoral artery for peripheral arterial cannulation during cardiopulmonary bypass (CPB) in aortic surgery. The aim of this study is to report our single-centre experience using direct axillary artery cannulation during aortic surgery. Methods: One hundred consecutive patients, undergoing aortic surgery using direct axillary artery cannulation were enrolled. Patient population ranged between 29 to 87 years and mean age was 65 ± 13 years. Seventy-seven patients (77%) underwent scheduled complex surgical procedure and 23 patients (23%) underwent emergent surgical procedure. Sixteen patients, furthermore, have had a previous cardiac surgery procedure. Results: CPB management using direct axillary artery cannulation was satisfactory in all cases. No case of malperfusion (cerebral and/or visceral) was reported. Out of 100 patients undergoing direct cannulation of axillary artery, no major complications related to the site or the technique of the cannulation were recorded. Local minor complications were reported in 6 patients (6%). In all 6 patients such complications were transitory and there was no residual compromission at the discharge. Overall 30-days mortality was 16%. Twenty-two patients (22%) conversely were discharged directly from intensive care unit (ICU) to chronic rehabilitation center. Sixty-seven patients (67%) were successfully discharged home. Conclusions: Our experience clearly shows that direct axillary artery cannulation is a safe, effective and reproducible technique for arterial cannulation during complex surgical procedures involving thoracic aorta. We do support such approach as a first choice strategy in such circumstances.

Effectiveness of ultrasound-guided peripheral arterial cannulation in neonates, including very low birth weight infants who are conventionally difficult-to-cannulate: a case series.

The effectiveness of ultrasound-guided peripheral arterial cannulation (UGPAC) in children has been increasingly been reported. However, to the best of our knowledge, there have been no reports of UGPAC in neonates, including very low birth weight infants (VLBWIs). In this study, we aimed to retrospectively review the results of UGPAC in neonates, including VLBWIs, and assess its effectiveness. This case series was conducted in a tertiary neonatal intensive care unit (NICU) in Japan. We included neonates aged below 28days who underwent UGPAC in our NICU between April 2021 and October 2022. We extracted the following data from medical records and analysed it retrospectively: patient age (days), postconceptional age, patient weight at the time of cannulation, number of punctures using the conventional technique before ultrasound guidance was performed and number of punctures with the ultrasound-guided technique until successful cannulation. A total of 27 UGPACs were performed in 19 neonates, including 14 cannulations in 10 VLBWIs. In infants weighing > 1500g and VLBWIs, the success rate within the first three punctures was 100% (13/13) and 79% (11/14), respectively. Overall, 41% (11/27) of UGPACs were performed following failed punctures using conventional methods, with a 100% success rate within the first three attempts. In all cases, no apparent adverse events, such as hypothermia, were noted. Conclusions: Our results suggest that UGPAC had a high success rate in neonates, including VLBWIs. Further studies are required to compare the effectiveness of UGPAC with conventional methods in neonates. What is Known: • The use of ultrasound guidance for arterial cannulation is recommended in children. • Ultrasound-guided peripheral arterial cannulation (UGPAC) in neonates, including very low birth weight infants (VLBWIs), has not been reported. What is New: • UGPAC in neonates, including VLBWIs, was performed with a high success rate; approximately 40% of UGPACs were performed after the failure of the conventional methods. • This study suggested the effectiveness of UGPAC in neonates, including VLBWIs.

74: Artery Morphology Following Peripheral Arterial Cannulation in Neonates and Children

74: Artery Morphology Following Peripheral Arterial Cannulation in Neonates and Children

A retrospective observational study of real-time ultrasound-guided peripheral arterial cannulation in infants.

To examine first attempt success and overall success of real-time ultrasound guided peripheral arterial cannulation in infants. Retrospective review of 477 ultrasound guided peripheral arterial cannulations in infants less than 1 year of age. Procedural and patient characteristics were evaluated to better understand factors related to procedural success. Ultrasound guided peripheral arterial cannulation had a first attempt success rate of 65% and an overall success rate of 86%. Success rates significantly differed by arterial location (p < 0.001). First attempt success and overall success were highest in the radial artery (72%, 91%) and lowest in the posterior tibial artery (44%, 71%). Success was more likely with greater age and greater weight (p = 0.006, p = 0.002). Success rates are high when using a real-time ultrasound-guided technique for peripheral arterial cannulation in infants. An infant's weight and selected artery are strong predictors of success when performing peripheral arterial cannulation. The use of procedural ultrasound may reduce unnecessary attempts and minimize procedure-related harm.

Safe Insertion of Arterial Catheters (SIA): An ultrasound-guided protocol to minimize complications for arterial cannulation.

Direct puncture and cannulation of peripheral arteries is frequently performed in critical care and in emergency settings, mainly for hemodynamic monitoring and blood sampling. While there is abundant literature on peripheral arterial cannulation in children and adults, there is still scope for clinical improvements which may impact on patient safety. Although the radial artery is the most frequently utilized access site today, due to its superficial proximity, ease of access, and low risk of adverse events, other sites are sometimes chosen. The authors propose the Safe Insertion of Arterial Catheters (SIA) protocol, an ultrasound-guided insertion bundle applying a systematic approach to arterial cannulation, with a focus on improving insertion practices, reducing procedural complications, increasing the patient safety profile, and improving device performance.

P47 MITRAL VALVE RE–REPAIR THROUGH A RIGHT MINITHORACOTOMY

Abstract Objective Recurrent mitral valve regurgitation after prior repair is usually treated with re–repair or replacement through a median sternotomy. We report our small initial experience with mitral valve re–repair through a repeated minimally invasive approach. Methods From July 2018 to November 2021, 10 patients (median age 52 years IQR 49–68; male 90%) underwent isolated mitral valve re–repair with a right mini–thoracotomy approach with peripheral arterial and venous cannulation. Median Euroscore II was 2.05 (IQR 2.03–2.54). Results The median time from the original operation to redo surgery was 4.7 (3.5–8.1) years. Median cardiopulmonary bypass and cross–clamp times were 128 (IQR 109–134) and 99.5 (IQR 81–112) minutes, respectively. Failure of previous mitral valve repair was mainly due to Gore–Tex chordal rupture (3 patients), annular detachment (3 patients), native chordal rupture (2 patients), and posterior leaflet prolapse (2 patients). Concerning the surgical terchnique, a complete mitral valve ring Corcym Memo 3D or 4D was used in 8 patients while additional repair techniques were needed 5 patients (PTFE neochords implantation, cleft or commissure closure). No conversion to full sternotomy and no reoperation for bleeding was necessary. Median ICU and hospital stay were 2.0 (IQR 2.0–2.0) and 7.5 (7.0–9.0) days respectively. Median follow up time was 3.5 (2.8–3.9) years. Neither deaths nor major postoperative complications occurred in the follow–up period. Conclusions In our experience, mitral valve re–repair can be an attractive option for patients with failure of previous mitral valve surgery and can be safely performed through a minimally invasive approach with good outcomes. Main advantages seem to be the avoidance of extensive surgical dissection, optimal valve exposure, and low risk of surgical complications.

Totally Endoscopic Constrictive Pericarditis Treatment: A Case Series.

Minimally invasive cardiac surgery has increased in popularity to reduce the morbidity associated with open heart surgery. In this article, a totally endoscopic case series is presented in which anterior pericardiectomy is performed by peripheral femoral arterial and venous cannulation. Right periareoal incision and right submammary incision were used for male and female patients, respectively, to access the heart by the fourth intercostal space.

Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis.

It is unclear whether peripheral arterial cannulation is superior to central arterial cannulation for postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO). A systematic review was conducted using PubMed, Scopus, and Google Scholar to identify studies on postcardiotomy VA-ECMO for the present individual patient data (IPD) meta-analysis. Analysis was performed according to the intention-to-treat principle. The investigators of 10 studies agreed to participate in the present IPD meta-analysis. Overall, 1269 patients were included in the analysis. Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA-ECMO were 70.7% vs. 63.7%, respectively (adjusted OR 1.38, 95% CI 1.08-1.75). Propensity score matching yielded 538 pairs of patients with balanced baseline characteristics and operative variables. Among these matched cohorts, central arterial cannulation VA-ECMO was associated with significantly higher in-hospital mortality compared to peripheral arterial cannulation VA-ECMO (64.5% vs. 70.8%, p = 0.027). These findings were confirmed by aggregate data meta-analysis, which showed that central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation (OR 1.35, 95% CI 1.04-1.76, I2 21%). Among patients requiring postcardiotomy VA-ECMO, central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation. This increased risk is of limited magnitude, and further studies are needed to confirm the present findings and to identify the mechanisms underlying the potential beneficial effects of peripheral VA-ECMO.

Local nitroglycerin to facilitate peripheral arterial cannulation in children: systematic review and meta-analysis

BackgroundNeonates and children admitted to intensive care units require peripheral arterial cannulation to monitor their blood pressures and for blood sampling, but many times it is unsuccessful.ObjectiveTo conduct a systematic...

Poor Outcomes of Pediatric Acute Compartment Syndrome in the Setting of Extracorporeal Membrane Oxygenation: A Multicenter Case Series.

Acute compartment syndrome (ACS) is a well-described condition that merits emergent surgical decompression. Peripheral arterial cannulation can increase the likelihood of ACS in patients requiring extracorporeal membranous oxygen (ECMO). Comorbidities in these critically ill patients may portend negative consequences of decompressive fasciotomy. This study investigated the clinical short-term and mid-term outcomes in pediatric patients with ECMO-associated ACS. This is a retrospective case series at 3 pediatric hospitals from 2006 to 2019, including children ages 0 to 19 years who underwent peripheral arterial cannulation and developed ACS. Eighteen patients developed ACS after receiving peripheral cannulation ECMO. Mean time to diagnosis after cannulation was 63.1 hours. All patients were diagnosed clinically; the most common findings were tight compartments, swelling, and loss of peripheral pulses. Eight patients (44%) died due to underlying illness. Treating physicians decided against decompression for 5 patients due to their underlying illness, instability, and concern for infection. Thirteen patients (72%) underwent decompressive fasciotomies. Ten surgical patients required subsequent surgeries and 6 (33%) developed surgical site infections. Of the 7 surviving surgical patients, 4 (57%) required extremity amputations and 4 had lower extremity neurological deficits on follow-up. Two of 3 nonsurgical patients (66%) had functional lower extremity motor deficits on follow-up. No surviving nonoperative patients developed infections or required amputations. ACS on ECMO is associated with high rates of complications including neurologic deficits, infection, and amputation. Patients treated nonoperatively avoided complications such as infection and amputation, but had more functional neurological deficits than surgical patients. Orthopaedic surgeons should consider the high morbidity of compartment release in these critically ill patients and, with critical care teams, assess whether the potential benefits of surgery outweigh expected risks. Level IV.

Comparison of Invasive Arterial Blood Pressure Monitoring vs. Non-Invasive Blood Pressure Monitoring in Preterm Infants < 37 Weeks in the Neonatal Intensive Care Unit- A Prospective Observational Study.

Accurate measurement of blood pressure (BP) is extremely important in the management of sick preterm newborns. The primary objective of this study was to compare non-invasive blood pressure measurement (NIBP) with invasive blood pressure measurement (IBP) using peripheral arterial cannulation (PAC) in preterm neonates < 37 weeks in the neonatal intensive care unit. Preterm neonates needing PAC were prospectively enrolled in the study. NIBP measurements were taken in the same limb as that of peripheral arterial line. Initially IBP was recorded followed by NIBP within 1 min using the same monitor. These were called as paired measurements since they are taken within 1 min of each other. Seventy-three preterm infants with 1703 paired measurements were included in the final analysis (median gestational age 32 weeks, IQR 30-34 weeks, median birth weight 1540 g, IQR 1160-2100 g). In preterm infants not receiving vasoactive agents (n = 51, 1428 paired measurements, Bland-Altman analysis for agreement between invasive mean blood pressure (MBP) and non-invasive mean BP revealed a bias of -2.9123 mmHg (SD 7.8074). The 95% limits of agreement were from -18.2157 to 12.3893 mmHg. In preterm infants with hypotension, we detected a bias of -3.9176 mmHg (SD 5.1135) between invasive MBP and non-invasive MBP. The 95% limits of agreement were from -13.9401 to 6.1048 mmHg. In normotensive preterm infants receiving vasoactive agents, we detected a bias of -0.7629 mmHg (SD 8.0539) between invasive MBP and non-invasive MBP. The 95% limits of agreement were from -16.5485 to 15.02274 mmHg. There is poor level of agreement between IBP and NIBP measurements in sick preterm neonates, leading to overestimation or underestimation of blood pressure. The bias was less for mean BP measurements as compared with systolic BP measurements and also for normotensive neonates as compared with hypotensive neonates. Hence, NIBP may be used as a screening method in haemodynamically stable preterm infants, but infants who are haemodynamically unstable and need to be commenced on vasoactive agents should have IBP monitoring.

Clinical experience of use of percutaneous peripheral arterial cannulation in sick neonates in a developing country

BackgroundContinuous invasive arterial monitoring is necessary in sick neonates needing hemodynamic and ventilatory support. The primary objective of our study was to describe clinical experience with percutaneous peripheral arterial cannulation (PAC) in sick neonates.MethodsNeonates needing PAC were prospectively enrolled in the study. Inclusion criteria were: neonates needing respiratory support (invasive or non-invasive), neonates requiring vasoactive medications or neonate likely to need more than 5 sampling pricks in 24 h.ResultsOne hundred eight neonates (93.1%) needed cannulation of one arterial site while 8 (6.9%) needed cannulation of 2 arterial sites, thus giving a total of 124 cannulations. Out of the 124 cannulations, 102 (82%) were performed in first attempt, while 22 (18%) cannulations needed 2 or more attempts. Serious complications like discolouration of digits, blanching of skin or bleeding were seen in 6 (4.9%) cannulations. These resolved after removal of arterial line and no long term consequences were noted. On comparing neonates having radial arterial cannulation(n = 108) with posterior tibial arterial cannulation (n = 16) there was no difference in duration of arterial line between radial artery group (mean, SD 53.30 ± 22.56) and posterior tibial artery group (mean, SD 48.25 ± 27.39). However, more attempts were needed to cannulate post tibial artery (mean, SD 2.25 ± 1.32) as compared to radial artery (mean 1.22 ± 0.789) and this difference was statistically significant (MD -1.02, 95% CI − 1.75 to − 0.30). There was no difference in incidence of serious complications between the radial artery group (3.7%, n = 4) as compared to posterior tibial group (5.5%, n = 1, OR 0.57, 95% CI 0.06–5.51, p = 0.63).ConclusionsPeripheral arterial cannulation is a safe method for hemodynamic monitoring and blood sampling in sick neonates. Complications can be minimized by diligent monitoring and proactive removal of line if there is damping of tracing.

NEAR-INFRARED SPECTROSCOPY FOR MONITORING DISTAL LIMB PERFUSION DURING PEDIATRIC MINIMAL INVASIVE CARDIAC SURGERY FOR CONGENITAL HEART DEFECTS

Introduction Acute femoral artery occlusion due to remote access bypass (femoral arterial cannulation), is a routine for pediatric minimal invasive cardiac surgery and prevention of leg ischemia is necessary. This technique requires peripheral vessel cross clamping, which may lead to transient perfusion deficit of the lower extremities.Strategies to prevent muscle necrosis or development of compartment syndrome include invasive or non-invasive monitoring of tissue oxygen saturation of involved extremity. A variety of means are utilized, to assess lower extremity (LE) perfusion – including pulse palpation, pulse oximetry, subjective assessment of LE by colour, temperature etc. Regional oxygen saturation measured by near-infrared spectroscopy (NIRS), used as a potential surrogate of cerebral and somatic mixed venous oxygen saturation-is a noninvasive tool to continuously monitor LE perfusion. We sought to evaluate the safety of peripheral arterial cannulation by using NIRS in such subset of patients. Methods We evaluated 50 pediatric patients, weight 10-30kg, age 3-12years, divided in: Group A (N=25), - underwent peripheral femoral artery cannulation for remote access perfusion for MICS, group B (N=25), receive conventional sternotomy incision. All patients were monitored by transcutaneous NIRS (placed on calves of both legs) for quality control of distal leg perfusion during cardiopulmonary bypass. Baseline NIRS value, followed by continuous NIRS values were recorded. Total creatinine kinase (CK) and serum myoglobin levels, mid-thigh and mid -calf circumference (to rule out compartment syndrome), were measured at preoperatively, 6hour and 24hour after surgery. Intra-operatively, all hemodynamic parameters along with blood gas parameters like PH, PO2, PCO2, SCVO2, lactate etc. were recorded at baseline, on bypass, clamp on, clamp off and off bypass period. Total CPB time, ventilation duration, hospital and ICU stay were also recorded. Results The baseline NIRS comparable in group A (72.6±6.86) over cannulated versus (71.76±4.05), contralateral leg, while, in group B, it was (69.96±5.75 vs.69.84±5.50). During clamping of femoral artery in Group A, NIRS dropped to 39.12±5.60 (vs. baseline), while it remained stable in the contralateral leg and group B patients. After successful implantation of the distal leg perfusion, the NIRS normalized to baseline within 5 to 7 minutes. Myoglobin and CK levels increased in both the groups, more so in Group A. There were no clinical side effects from increased CK or myoglobin. None of our patients had residual vascular complications. ±±±± Discussion We speculate that remote CPB with direct femoral artery cannulation can be safely used in pediatric patients- with a body weight 10-30 kg and CPB time less than 60 minutes- without increasing operative morbidity and complications. When prolonged CPB time is expected probably one should change the MICS policy by adding selective distal leg perfusion to minimize the complications

Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an established last line support for severe, acute cardiorespiratory failure. In the case of VA ECMO, peripheral cannulation via the femoral vessels is often advantageous when compared with the alternative central cannulation, and is associated with better clinical outcomes. One of the specific potential complications of peripheral femoral arterial cannulation for ECMO, however, is ipsilateral distal lower limb ischemia; a consideration especially when cannulating the vessel directly, as distal limb perfusion is invariably compromised by an occlusive effect of the arterial cannula within the femoral artery. The gold standard technique for lower limb reperfusion is a separate size 6-7 Fr cannula inserted proximally into the femoral artery, just below the insertion point of the ECMO return cannula, and connected directly to the ECMO circuit so that the blood flow is also directed distally to perfuse the entire limb. This functions well whether the ECMO cannula has been placed percutaneously or by surgical cut-down. Although proximal femoral arterial placement of the reperfusion cannula is the established and preferred technique, there are many technical challenges which may preclude its placement. Local haematoma or bleeding post ECMO insertion, peripheral vascular disease, constricted vasculature in severely shocked patients, or patient obesity are all common reasons why placement of the proximal reperfusion cannula may be difficult, or impossible. In such instances, our retrograde perfusion technique may maintain limb perfusion and may even be limb saving for patients on VA ECMO support.

Direct Aortic Versus Peripheral Arterial Cannulation in Surgery for Type A Aortic Dissection

It is controversial whether peripheral arterial cannulation may achieve better results than direct aortic cannulation during surgery for Stanford type A aortic dissection. From January 2005 to December 2017, 309 consecutive patients underwent surgical repair for acute type A aortic dissection at Helsinki University Hospital, Finland. The early outcomes of patients who underwent surgery with direct aortic cannulation were compared with those of patients in whom peripheral arterial cannulation was used. Direct aortic cannulation was used in 80 patients and peripheral arterial cannulation in 229 patients. Patients who underwent surgery with direct aortic cannulation had hospital mortality (13.8% vs 13.5%, P= .962) and stroke/global brain ischemia (22.3% vs 25%, P= .617) similar to that of patients who had peripheral arterial cannulation. The other secondary outcomes were equally distributed between the unmatched study cohorts. Among 74 propensity score matched pairs, direct aortic cannulation had hospital mortality rates (12.2% vs 9.5%, P= .804) and stroke/global brain ischemia rates (21.6% vs 21.6%, P= 1.000) comparable to those for peripheral arterial cannulation. The composite outcome of hospital mortality/stroke/global brain ischemia (29.7% vs 27%, P= .855), multiple stroke (16.2% vs 17.6%, P= 1.000), renal replacement therapy (11.8% vs 13%, P= 1.000) and length of stay in the intensive care unit (mean, 4.9 ± 4.5 vs 4.8 ± 4.9 days, P= .943) were also equally distributed between these matched cohorts. In this institutional series, central arterial cannulation allowed a straightforward surgical repair of type A aortic dissection and achieved early outcomes similar to those of peripheral arterial cannulation.

Video assisted right mini-thoracotomy for aortic root replacement.

Aortic root replacement is typically performed through a median sternotomy. The right anterior mini-thoracotomy approach has been shown to decrease hospital length of stay in aortic valve surgery when compared to sternotomy. This approach is rare in ascending aortic surgery due to technical challenges which include exposure and annular suture placement. Automated suturing technology is now available to facilitate the placement of annular sutures. The use of a camera greatly enhances visualization of the aortic root. A right anterior mini-thoracotomy is performed via a 5 cm incision in the right second intercostal space with a camera port placed lateral to the incision. Peripheral arterial and venous cannulation are performed. The aortic cross clamp is placed through a 5 mm incision in the third interspace anterior to mid axillary line. Histidine tryptophan ketoglutarate (HTK) cardioplegia is administered and deep hypothermic circulatory arrest is achieved followed by completion of the distal anastomosis with a 4-0 polypropylene running suture. After aortic leaflet removal, annular and prosthetic sutures are placed with shafted instruments or with automated suturing technology. Coronary button suturing and graft-to-graft anastomoses are performed with shafted instruments. Aortic root procedures can be performed safely through a right anterior mini-thoracotomy. The use of a camera and automated suturing technology may further facilitate this procedure, enabling more surgeons to offer this less invasive approach to patients.

СРАВНЕНИЕ ДВУХ МЕТОДИК КАТЕТЕРИЗАЦИИ ЛУЧЕВОЙ АРТЕРИИ: ПАЛЬПАТОРНОЙ И С УЛЬТРАЗВУКОВЫМ КОНТРОЛЕМ

Anatomical landmarks and palpation are traditionally used for radial arterial catheterization in emergency units. Despite the successful use of ultrasound monitoring for central venous access, there is a lack of evidence about the benefits of the ultrasound guidance for peripheral arterial cannulation. The objective: to compare two methods of radial arterial catheterization (the traditional one based on palpation and the method under ultrasound guidance) in the patients undergoing planned surgery. Subjects and methods. 40 patients participated in the prospective cohort study, all of them had planned surgeries. In Group 1, the traditional method was used for arterial catheterization (the palpation group), and in Group 2 it was done under ultrasound guidance (the ultrasound group). The following parameters were recorded for both groups: number of attempts, number of puncture sites, complications and their type, time of catheterization. The number of cannulation attempts was taken as a primary endpoint. Results. The statistically significant correlation was found between the method of catheterization and the number of attempts (Pearson's ch i-s quared test = 29.562, df = 6, p < 0.001), places of puncture (Pearson's ch i-s quared test = 10.365, df = 3, p = 0.015). In the ultrasound group, the first attempt of cannulation was a success in 19 cases (95%; CI 73−99%), while in the palpation group, the first attempt was a success in 2 cases (10%; CI 2−33%). The one catheterization site was used in 95% of cases in the ultrasound group ( CI 73−99%; 1 observation). While in Group 2 (the palpation group), two sites of cannulation and more were required in 50% of patients ( CI 30−17%; 10 observations). Among complications there were hematomas, and no statistically significant correlations were found between the method of puncture and their number in the groups (Pearson's ch i-s quared test = 2.7706, df = 1, p = 0.09601). The time spent on catheterization in the ultrasound group was shorter versus the palpation group (W = 344, p < 0.001) and it made 101 sec. (51; 144) and 194 sec. (153; 311) respectively. Conclusion: Compared to the traditional (palpation) method, the radial arterial catheterization guided by ultrasound possesses such benefits as high chances of successful cannulation with the first attempt, fewer sites required to provide arterial access and total time required for the manipulation.

Direct axillary cannulation with open Seldinger-guided technique: is it safe?

Axillary artery cannulation is commonly used in thoracic aortic surgery, often utilizing a sidearm graft. Although our institutional preference is femoral cannulation, we use axillary cannulation in select cases with a 'dirty' aorta on computed tomography scan or intraoperative transoesophageal echocardiography. Since 2011, we have routinely used an open Seldinger-guided approach for axillary cannulation. Here, we report our experience with open Seldinger-guided technique, evaluating its safety and efficacy. A retrospective analysis of our institutional database from 2011 to 2016 was performed to find cases of peripheral arterial cannulation for thoracic aortic surgery. We identified 404 consecutive patients who underwent peripheral arterial cannulation. Of these, 352 were femoral and 52 were axillary cannulations. All axillary cannulations were performed for ascending and/or arch surgery. The technique involves a surgical exposure of the artery which is then cannulated by guidewire inside a purse string without arterial incision. Indications for surgery included aneurysm in 63.5% (33/52), dissection in 30.7% (16/52) and pseudoaneurysm in the remaining 5.8% (3/52). Hospital survival was 98.1% (51/52). There were no instances of axillary arterial injury or intraoperative malperfusion phenomena. No postoperative limb ischaemia or stroke was evident. No wound infections or late pseudoaneurysms were observed. The open Seldinger-guided technique for axillary artery cannulation is safe and effective. We strongly recommend this technique, given its speed and simplicity. The vessel is not snared, thereby preserving distal arterial flow and minimizing the risk of acute limb ischaemia. Furthermore, the limited manipulation of the artery lowers the risk of local complications.

An alternative peripheral arterial cannulation in minimally invasive and robotic cardiac surgery

An alternative peripheral arterial cannulation in minimally invasive and robotic cardiac surgery

Identification and confirmation of suspected unintended peripheral arterial cannulation during anaesthesia

Unintended arterial cannulation and injection of drugs may result in ischaemia and tissue necrosis. Various methods used to differentiate accidental arterial from intravenous cannulation have their own shortcomings. Here we present the case of a 13-year-old girl having an elective procedure under general anaesthesia and the challenges faced in distinguishing suspected intra-arterial cannulation from what was indeed an intravenous cannulation. We recommend the use of an open-ended saline-filled ‘T’ connector–syringe system and pressure transduction as the methods of choice to identify and confirm, respectively, a suspected arterial cannulation during anaesthesia.