Subclavian Artery Cannulation Research Articles

Patient-Specific Computational Modeling of Different Cannulation Strategies for Extracorporeal Membrane Oxygenation.

Institution of extracorporeal membrane oxygenation (ECMO) results in unique blood flow characteristics to the end-organ vascular beds. We studied the interplay between cardiac-driven and extracorporeal membrane oxygenation (ECMO)-driven flow to vascular beds in different ECMO configurations using a patient-specific computational fluid dynamics (CFD) analysis. A computational ECMO model (femoral artery cannulation [FAC]) was constructed using patient-specific imaging and hemodynamic data. Following model calibration, we augmented the 3D geometrical model to represent alternative ECMO configurations (ascending aorta cannulation [AAC] and subclavian artery cannulation [SAC]). We performed CFD analyses, including a novel virtual color-dye analysis to compare global and regional blood flow and pressure characteristics as well as contributions of cardiac and ECMO-derived flow to the various vascular beds. Flow waveforms at all the aortic branch vessels were pulsatile, despite low cardiac output and predominant nonpulsatile ECMO-driven hemodynamics. Virtual color-dye analysis revealed differential contribution of cardiac and ECMO-derived flow to the end-organ vascular beds in the FAC model, while this was more evenly distributed in the AAC and SAC models. While global hemodynamics were relatively similar between various ECMO configurations, several distinct hemodynamic indices, in particular wall shear stress and oscillatory shear patterns, as well as differential contribution of ECMO-derived flow to various vascular beds, showed remarkable differences. The clinical impact of this study highlighting the relevance of CFD modeling in assessment of complex hemodynamics in ECMO warrants further evaluation.

Subclavian versus femoral arterial cannulations during extracorporeal membrane oxygenation: A propensity-matched comparison.

During peripheral extracorporeal veno-arterial membrane oxygenation (VA-ECMO) support, subclavian arterial cannulation provides, in comparison to femoral arterial cannulation, an anterograde flow which may prevent from left ventricular (LV) distention and improve outcomes. We aimed to compare the effectiveness of subclavian cannulation to femoral cannulation in reducing LV overdistension consequences, hemostatic complications and mortality. This retrospective study conducted in two intensive care units of the Lille academic hospitals from January 2013 to December 2019 included 372 non-moribund adult patients supported by VA-ECMO. The primary endpoint was a new onset of pulmonary edema (PO) or LV unloading. Secondary endpoints were myocardial recovery, serious bleeding (according to Extracorporeal Life Support Organization definition), thrombotic complications (a composite of stroke, cannulated limb or mesenteric ischemia, intracardiac or aortic-root thrombosis) and 28 day mortality. Differences in outcomes were analyzed using propensity score matching (PSM) and inverse probability of treatment weighting adjustment (IPTW). As compared to femoral cannulation (n=320 patients), subclavian cannulation (n=52 patients) did not reduce the occurrence of new onset of PO or LV unloading after PSM [HR 0.99 (95% CI 0.51-1.91)]. There was no other difference in outcomes in PSM cohort. In IPTW adjustment cohort, subclavian cannulation was associated with reduced recovery and increased serious bleeding with four accidental decannulations observed. Subclavian artery cannulation was not associated with reduced LV distension related complications, thrombotic complications and 28 day mortality. Rather, it may increase serious bleeding and accidental decannulations, and reduce recovery. Therefore, subclavian cannulation should be limited to vascular accessibility issues.

Outcome of emergency surgery for acute type A aortic dissection in octogenarians.

Emergency surgery for acute type A aortic dissection (AAAD) was usually avoided or denied in octogenarians because of high surgical mortality. Refined surgical techniques and improved postoperative care have led to an improved in-hospital outcome. However, a significant number of operative survivors suffered from postoperative complications and had compromised quality of life. We sought to assess the clinical outcome of emergency surgery using a standard conservative approach in octogenarians with AAAD. From 2004 to 2021, 123 patients underwent emergency surgery for AAAD by one surgeon using a standard conservative approach with right subclavian artery cannulation, no aortic cross-clamp, selective antegrade cerebral perfusion, moderate systemic hypothermia, reinforced sandwich technique, and a strategy of limited aortic resection. Hospital and late outcomes were assessed in patients with age >80 years. Eighteen patients (15%) were octogenarians with seven males (39%) and median age of 82 years (range, 80-89). Hypertension was present in six patients (33%). None had diabetes mellitus, Marfan, or bicuspid aortic valve. Dissection was intramural hematoma in six (33%) and DeBakey type I in 15 patients (83%). Cardiac tamponade with shock was present in seven patients (39%). Ascending aortic grafting was performed in 17 patients, and additional hemiarch replacement in one patient. The hospital mortality rate was 17% (3/18). Fourteen patients (82%) were alive and well at discharge. Emergency surgery for AAAD using a standard conservative approach showed an improved outcome in octogenarians. The majority of patients could return home with an acceptable living.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

Direct proximal right subclavian artery cannulation during surgery of the thoracic aorta.

ObjectiveTo evaluate outcomes of single sternum access for right subclavian artery cannulation without infraclavicular incision in surgery of the thoracic aorta.MethodsBetween January 2015 and December 2019, 44 consecutive patients underwent surgery of the thoracic aorta with cannulation of the right subclavian artery, after sternotomy and before pericardiotomy, through a direct percutaneous cannula with a single access without additional infraclavicular skin incision. The indication for surgery was type A acute aortic dissection in 29 patients (65.9%), proximal aortic aneurysm in 11 (25%), and aneurysm of the aortic arch in 4 (9%). Operative procedures were replacement of the ascending aorta in 23 patients, Bentall procedure in 10, hemiarch replacement in 6, and total arch replacement in 5. The mean cardiopulmonary bypass (CPB) and cross-clamp times were 185 ± 62 minutes and 138 ± 41 minutes, respectively.ResultsThe in-hospital mortality rate was 6.8%. Permanent neurologic dysfunction occurred in 3 patients (6.8%) and temporary neurologic dysfunction occurred in 4 patients (9.0%). There were no vascular complications related to this technique. No lesions to the vagus and recurrent laryngeal nerves have been reported.ConclusionsIn our experience, a single sternum access for right subclavian artery cannulation avoids the risk and complications of an infraclavicular incision required for axillary artery cannulation. This technique is safe and represent a valid option for CBP and antegrade cerebral perfusion during surgery of the thoracic aorta.

Iatrogenic Subclavian Artery Cannulation

Iatrogenic Subclavian Artery Cannulation

Percutaneous Subclavian Artery Covered Stent Placement Following Inadvertent Subclavian Arterial Cannulation

Inadvertent subclavian artery canulation although rare is a life threatening complication of central venouscanulation. Its prompt recognition and management by stent placement, thrombin injection, Angio seal orgel foam embolization is essential to minimize fatal complications. We describe a case report of subclavianarterial canulation which was recognized and managed percutaneously by covered stent placement withoutcomplications.

Optimization of the total arch replacement technique: Left subclavian perfusion with sequential aortic reconstruction

Despite many technical improvements, total arch replacement is still associated with a high risk of stroke and paraplegia, which is largely ascribed to the long duration of hypothermic circulatory arrest (HCA) and cerebral ischemia.1 We have optimized our current total arch replacement technique2,3 by using left subclavian artery (LSA) cannulation and sequential aortic reconstruction to decrease the time of HCA and cerebral and spinal cord ischemia, which has achieved encouraging preliminary results.

Subclavian Artery Versus Femoral Artery Cannulation as An Access for Cardiopulmonary Bypass in Repair of Acute Type A Aortic Dissection

Background: Although many studies have reported the advantages and disadvantages between subclavian and femoral and cannulation, however most of these studies reported results for all patients underwent deep hypothermic circulatory arrest (DHCA) with ascending and aortic arch surgery with different pathologies. Objective: In our study we compared femoral and subclavian artery cannulation and reported the results only for the ascending aorta with acute type A aortic dissection (ATAAD). Patients and Methods: From January 2017 to January 2018 in Cairo University Hospitals, we selected 100 patients presented with acute type A aortic dissection and underwent reconstruction of only the ascending aorta. Patients were divided into two groups, Group (A): includes patients with subclavian artery cannulation to establish cardiopulmonary bypass (CPB) and Group (B): includes patients with femoral artery cannulation to establish CPB. Early postoperative results during hospital stay and mortality were reported and compared between the groups. Results: The preoperative data in both groups showed no statistical difference in both groups, in postoperative data only Subclavian cannulation had a better cerebral protection and lower hospital stay than femoral cannulation (2 vs 8%, p = 0.04) while other postoperative data as well as mortality showed no statistical differences in both groups. Conclusions: From results of our study we concluded that subclavian cannulation is better than femoral cannulation in repair of type A aortic dissection as it has better cerebral protection and lower postoperative hospital stay.

Intrathoracic right subclavian artery cannulation in aortic arch surgery.

Intrathoracic right subclavian artery cannulation in aortic arch surgery.

Treatment of inadvertent subclavian artery cannulation with a percutaneous vascular closure device

Inadvertent puncture of the subclavian artery is an uncommon but potentially fatal complication of the commonly performed internal jugular vein catheterization. We report a case of accidental subclavian artery catheterization close to the vertebral artery during internal jugular venous cannulation, which was successfully managed in the interventional suite with catheter removal and use of a vascular closure device.

Percutaneous or Side-Arm Graft Right Subclavian Artery Cannulation via Median Sternotomy.

Several cannulation sites alternative to the ascending aorta, such as femoral, right axillary, carotid, innominate artery, and, less commonly, apical sites, have been proposed. Cannulation of the right subclavian artery, through sternotomy, is one possible means of establishing cardiopulmonary bypass, hence avoiding a second surgical incision. In our experience, cardiopulmonary bypass flow was adequate and circulatory arrest with antegrade cerebral perfusion was successfully performed in all cases. There was no in-hospital mortality.

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Transesophageal echocardiography evaluation of the aortic arch branches.

Visualization of aortic arch branches by transesophageal echocardiography has been technically challenging. Visualizing these vessels helps in identifying the extent of dissection of the aorta, assessing the severity of carotid artery stenosis, presence of atheromatous plaques, patency of the left internal mammary artery graft, confirmation of subclavian artery cannulation, confirming holodiastolic flow reversal in the left subclavian artery by spectral Doppler imaging in case of severe aortic regurgitation, and confirming the optimal position of the intraaortic balloon perioperatively. The information obtained is helpful for diagnosis, monitoring, and decision-making during aortic surgery.

The "Central Sport Model": Extracorporeal Membrane Oxygenation Using the Innominate Artery for Smaller Patients as Bridge to Lung Transplantation.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) may be used in patients with advanced cardiac or pulmonary failure. Arterial cannulation via the femoral arteries is suboptimal in many clinical scenarios because of associated complications and the potential for differential hypoxemia between the upper and lower body. To address these concerns, we typically use an upper body configuration (sport model) with right internal jugular and axillary or subclavian artery cannulation to allow a safe and durable means of providing VA ECMO support without differential hypoxemia. Unfortunately, this approach may not be feasible in smaller patients, whose vessels may preclude optimal use of the axillary or subclavian arteries and in those with systemic vasculopathy associated with connective tissue disorders. We describe a new approach for patients of small stature using the innominate artery through a mini-upper sternotomy in seven patients.

Computational fluid dynamics simulation of the right subclavian artery cannulation

ObjectiveThe purpose of this study was to evaluate the efficacy of right subclavian artery cannulation using computational fluid dynamics. MethodsPatient-specific models of the aortic arch were made with 4 patterns (1: normal aorta, 2: ascending aorta aneurysm, 3: distal arch aneurysm, 4: bovine arch) based on the computed tomography images. Right subclavian artery and ascending aorta cannulation models were created to simulate the physiologic pulsatile flow. Perfusion flow through the arterial cannula was set to 2.50 L/min (50% flow), 3.75 L/min (75% flow), and 5.0 L/min (100%), respectively, and a 3-dimensional movie was made of 1 cardiac cycle to evaluate the blood flow. ResultsIn both 50% and 75% flow simulation with right subclavian artery cannulation, the blood streamline from the right subclavian artery produced retrograde flow of the brachiocephalic artery and antegrade flow of the right common carotid artery throughout the cardiac cycle in all cases. Right subclavian artery flow deflected ascending aorta flow to the descending aorta. Left-side supra-aortic branches were perfused by blood flow from both the right subclavian artery cannula and the aortic valve. The ascending aortic cannulation model showed that blood flow from the aortic valve reached all 3 supra-aortic vessels in systole. ConclusionsRight subclavian artery cannulation was cerebroprotective, especially on the right side.

A Novel Technique of Subclavian Artery Cannulation for Venoarterial Extracorporeal Membrane Oxygenation.

The common femoral artery is the standard site for immediate vascular access when initiating adult venoarterial extracorporeal membrane oxygenation. However, this approach is fraught with problems such as femoral artery occlusion, distal limb ischemia, reperfusion injury resulting in compartment syndrome, retroperitoneal hemorrhage, thrombosis, embolization, and most importantly, pulmonary edema. Here, we show our preference of using the subclavian artery with a side graft as a different cannulation technique for outflow of extracorporeal membrane oxygenation, which can avoid complications associated with different access techniques. Between September 2013 and December 2014, our group established venoarterial extracorporeal membrane oxygenation via subclavian artery-percutaneous femoral vein cannulation in 11 patients (81.1% men). Mean age was 33 ± 11.1 years (range, 16-55 y). For this technique, the subclavian artery was slung by retrotapes (Retract-o-Tape; Quest Medical Inc. Allen, TX, USA) proximally and distally before arteriotomy. An 8-mm polyethylene terephthalate (Dacron) graft was then sutured in "end-to-side" fashion. The proximal retrotape was removed, and the distal retrotape was passed through a snare. This maneuver allowed us to manage distal flow of subclavian artery by tightening this tape, thus avoiding complications associated with right arm hyperperfusion. After venoarterial extracorporeal membrane oxygenation was established, central venous pressure and lactate levels decreased, and improvements in arterial blood-gas parameters were maintained. Our protocol for venoarterial extracorporeal membrane oxygenation cannulation uses the subclavian artery for arterial access and provides a safe and perhaps improved means for providing venoarterial extracorporeal membrane oxygenation support.

Should we change the cannulation site for right subclavian artery cannulation? An experimental study with a newly designed cannula.

In this experimental study, we primarily aimed to show the hemodynamic effects and superiority of this newly designed cannula for perfusion compared to standard subclavian cannulation. The new cannula (Figure 1) allows bidirectional axial flow and it directly fits in the brachiocephalic trunk (innominate artery). We used a cardiopulmonary bypass roller pump, reservoir, 3/8- 1/2- 1/4-inch Y-connectors and tubing set. Lines were set as seen in Figures 2, 3, 4 and 5. The anatomy of the aorta (ascending, arch, branches, descending) was mimicked, using tubing sets with different sizes and the connectors yielding similar angles and configurations. In this experimental vascular system, systemic vascular resistance was created with partial clamping of the common tubing set. The cannulation sites were created in the subclavian artery and the innominate artery. Perfusion was established with the same pump rate and the same occlusion pressures (systemic vascular resistance). The pressure readings were obtained in the right carotid artery, the left carotid artery and the left subclavian artery. These experimental models of vasculature allowed us to measure pressures in the carotid system for different cannulation set-ups, using both our newly designed double-outflow cannula, which was introduced via the innominate artery, and the standard arterial cannula, which was introduced via the subclavian artery. Higher pressure recordings were obtained in the carotid system with the new cannula introduced through innominate artery. Higher cerebral perfusion readings were obtained with our newly designed bidirectional cannula introduced via the innominate artery compared to standard cannulation through the right subclavian artery.

Inadvertent subclavian arterial cannulation

Inadvertent line insertion into the subclavian artery is an uncommon complication of subclavian venous catheterisation and its timely recognition is vital to minimise the risk of harm to the patient. We describe a patient who had an inadvertent subclavian arterial cannulation which was recognised within the first hour of insertion and subsequently removed without complications.

Endovascular Repair Using Suture-Mediated Closure Devices and Balloon Tamponade following Inadvertent Subclavian Artery Catheterization with Large-Caliber Hemodialysis Catheter.

Accidental subclavian artery cannulation is an uncommon but potentially serious complication of central venous catheterization. Removal of a catheter inadvertently placed in the subclavian artery can lead to substantial bleeding, as achieving hemostasis in this area through manual compression presents considerable difficulty. Additionally, surgical treatment might be unsuitable for high-risk patients due to comorbidities. Here, we report a case of an inadvertently-inserted 11.5-French hemodialysis catheter in the subclavian artery during internal jugular venous catheterization. We performed percutaneous closure of the subclavian artery using three 6-French Perclose Proglide® devices with a balloon tamponade in the proximal part of the subclavian artery. Closure was completed without embolic neurological complications.