Cannulation of the axillary artery for cardiopulmonary bypass: safeguards and pitfalls

BACKGROUND: The ascending aorta is the customary site for arterial cannulation for cardiopulmonary bypass. Favorable experience at our institution and elsewhere using axillary artery cannulation in treating type A aortic dissections has caused us to broaden our indications for using this site for arterial cannulation for cardiopulmonary bypass. METHODS: Medical records, operative notes, and perfusion records were reviewed in all patients in whom the axillary artery was cannulated directly or by a graft for cardiopulmonary bypass from January 1, 2000 through August 30, 2002. RESULTS: Seventy-five patients underwent axillary artery cannulation during the 32-month interval. Eleven patients had ascending aortic dissections, 20 had extensively diseased ascending aortas, and 44 were individuals undergoing repeat cardiac procedures. The right axillary artery was used in 72 patients and the left in 3. In 16 patients the artery was cannulated directly, and in 59 the arterial cannula was inserted into a prosthetic graft that had been anastomosed to the axillary artery. Axillary artery cannulation was satisfactory in 95% (71 of 75) of the cases in which it was used. CONCLUSIONS: Cannulation of the axillary artery for cardiopulmonary bypass is a dependable approach for procedures including reoperations, aortic dissections, and extensively diseased ascending aortas.     

Complications of ascending aortic intraaortic balloon pump cannulation

Choice of a route of cannulation for intraaortic balloon counterpulsation during cardiopulmonary bypass is related to accessibility. In those patients in whom it is impossible to pass the intraaortic balloon pump (IABP) into the common femoral artery, ascending aortic cannulation is a rapid and direct method of insertion. Eight patients are described in whom ascending aortic IABP cannulation was undertaken to enable weaning from cardiopulmonary bypass after cardiac surgical procedures. The following problems were encountered: graft infection, aberrant cannulation of the left subclavian artery, left coronary artery embolism, and inability to close the sternum due to mechanical tamponade. A technique is described for insertion of the IABP using a polytetrafluoroethylene (Impra) graft and closed-chest decannulation. Although considerable morbidity and mortality are associated with ascending aortic cannulation, it is simple, fast, and effective, and should be considered for all patients requiring postoperative IABP support in whom peripheral vascular disease makes access difficult.     

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.     

Coronary artery bypass grafting and replacement of aortic root and ascending aorta; report of a case

An 87-year-old man was referred to our hospital for chest oppression and syncope attack due to aortic stenosis. Further examination revealed severe aortic stenosis (pressure gradient of 107 mmHg, aortic valve area of 0.75 cm2), ascending aortic aneurysm (60 mm in diameter) and triple-vessel disease of coronary arteries. Therefore, a surgical operation was indicated electively. Under cardiopulmonary bypass with normothermia, coronary artery bypass grafting (CABG) was performed. Then the aortic root and the ascending aorta were replaced with a Freestyle valve (27 mm) and a woven Dacron graft (30 mm Hemashield with 1 branch), respectively. Duration of cardiopulmonary bypass and aortic cross-clamp was 267 and 203 minutes, respectively. Postoperative course was uneventful. On the 14th postoperative day, he underwent coronary and graft angiography, which showed all the grafts were patent with good flow. He was successfully discharged on the 19th postoperative day.     

Surgical treatment of ruptured aneurysms of the innominate artery

The cases of 3 patients with an aneurysm of the innominate artery treated surgically are reported. The clinical manifestations were different, and the surgical procedures employed also varied. In 1 patient, the neck of the aneurysm was isolated and clamped near the aortic arch. It was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. In the second, the aneurysm was resected under cardiopulmonary bypass, deep hypothermia, and total circulatory arrest. The neck was closed with a large Teflon patch, and a tube graft was interposed between the ascending aorta and the right carotid artery. In the third, a graft was interposed between both carotid arteries; conventional cardiopulmonary bypass was instituted, and the aorta was clamped between the innominate and the left carotid arteries. The neck of the aneurysm was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. All patients had an excellent postoperative course. Our comments regarding the clinical and surgical aspects of this condition are based on the present experience and reports in the literature.     

Use of saphenous vein graft in axillary artery cannulation

Axillary artery cannulation for cardiopulmonary bypass is becoming increasingly used for surgery of aortic dissections for reoperations and extensively diseased ascending aortas. This can be achieved either directly or with a graft. We describe a case with a repair of chronic type A dissection in which axillary cannulation was achieved by placing the arterial cannula into a saphenous vein graft that had been anastomosed end-to-side to the axillary artery. This provides a natural, inexpensive, readily available, and more hemostatic alternative to the use of prosthetic grafts.     

Surgery for distal aortic arch aneurysm with a patent left internal mammary-to-coronary artery graft; report of a case

We report a case of 62-year-old male who suffered from a distal aortic arch aneurysm developed 5 years after coronary artery bypass grafting (CABG). Preoperative angiography revealed a distal arch aneurysm and a patent left internal mammary artery (LIMA) graft. Graft replacement of the total aortic arch was performed using a 4 branched graft. After the re-median sternotomy, cardiopulmonary bypass was established with ascending aortic perfusion and right atrium (RA) drainage. Myocardial protection was achieved with root cold blood cardioplegia and LIMA continuous cold blood perfusion. Distal anastomosis was performed under selective cerebral perfusion and during deep hypothermic circulatory arrest. Postoperative course was satisfactory and the patient was discharged without complications.     

Aortic Dissections Complicating Open Cardiac Surgery: Report of Three Cases

Between June 1991 and February 1999, three patients suffered ascending aortic dissection as a complication of cardiopulmonary bypass operations with aortic cannulation at our hospital. The dissection occurred during the operation in two of the three patients and several months after the operation in one. Among a total of 2 207 cardiac operations performed during this period, the incidence of perioperative ascending aortic dissection was 0.14%. In addition to visual inspection and palpation, either epicardial or transesophageal echocardiography proved extremely useful for establishing an intraoperative diagnosis of ascending aortic dissection as a complication of open cardiac operation. One of the three patients underwent closed plication but subsequently died of vital organ ischemia. In this case, failure of reapproximation of the injured intima by closed plication might have led to extension of the dissection. Despite prolonged cardiopulmonary bypass and myocardial ischemic time, graft replacement of the ascending aorta was successfully carried out in the other two patients. Thus, we believe that graft replacement of the ascending aorta should be performed for patients with extensive aortic dissection complicating an open cardiac operation. Received: August 12, 1999 / Accepted: May 30, 2000     

The retroperitoneal, left flank approach to the supraceliac aorta for difficult and repeat aortic reconstructions.

Between 1986 and 1990, 11 patients with relative or absolute contraindications to standard infrarenal reconstructions underwent supraceliac aortofemoral bypass. The operation was performed through a left-flank incision extended into the eleventh intercostal space with retroperitoneal and extrapleural dissection. Indications included multiple failed infrarenal reconstructions in four patients, previous removal of infected aortofemoral bypass graft with failure of extra-anatomic bypass in five patients, prior para-aortic lymph node dissection and radiotherapy in one patient, and aortic aneurysmal disease proximal to the renal arteries in one patient. Bypass conduits included either a bifurcated Dacron graft or a tube graft to the left femoral artery with a femorofemoral cross-over graft; concomitant left renal artery reconstruction was performed in three patients. The mean supraceliac cross-clamp time was 24 minutes, and only one patient experienced transient postoperative acute tubular necrosis. There was no operative mortality. The graft limb patency was 95% after mean follow-up extending to 17 months (range: 5 months to 5 years). We conclude that the supraceliac aorta is a useful inflow source for aortofemoral reconstruction in difficult repeat cases. It can be approached easily without thoracotomy and avoids difficult infrarenal aortic dissection in a scarred field. The tunneling is easier than with descending thoracic aorta or ascending aorta inflow sources. In addition, this bypass is likely to be more durable than inflow reconstructions based on the axillary artery.     

Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the cabrol procedure

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.     

Thoracic endovascular aortic repair and off-pump coronary artery bypass grafting after renal transplantation: a case report

Twelve years after receiving a renal transplant, a 50-year-old woman developed asthmatic symptoms. Chest CT revealed a descending thoracic aortic aneurysm. She had undergone percutaneous coronary intervention to treat the left anterior descending artery 10 years earlier. Coronary artery angiography revealed restenosis of the left anterior descending artery (99%, #6 in-stent). Because cardiopulmonary bypass may cause problems for transplanted kidney, we performed off-pump coronary artery bypass grafting (left internal thoracic artery to left anterior descending artery) and thoracic endovascular graft placement to treat the aortic aneurysm. Considering that the artery of the transplanted kidney was attached to the right iliac artery, and then the left common femoral artery was selected as the access root for GORE TAG(?) endografts (34 × 200 and 34 × 150 mm) (stentgrafts were deployed for the descending aortic artery). Postoperative angiography showed a patent bypass graft. Postoperative CT confirmed the absence of endoleaks. The postoperative course was uneventful, and she was discharged without complications. Ischemic heart disease and descending thoracic aortic aneurysm in recipients of kidney transplants can be treated using off-pump coronary bypass grafting and thoracic endovascular graft placement. The transplanted kidney was protected without using cardiopulmonary bypass (CPB).     

Coronary artery bypass grafting in a case with severe aortic atheromatosis associated with abdominal aortic aneurysm

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was frist replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.     

Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the Cabrol procedure.

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.     

Coronary artery bypass grafting in a case with severe aortic atheromatosis associated with abdominal aortic aneurysm.

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was first replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.     

Surgical approach to combined coronary revascularization and abdominal aortic aneurysmectomy

Combined repair of peripheral vascular disease and myocardial revascularization has become accepted treatment in selected patients. Two of our patients underwent such a procedure. One patient suffered an intraoperative dissection of the ascending aorta following myocardial revascularization. Ascending aortic replacement and vein graft reimplantation was accomplished as well as repair of the abdominal aortic aneurysm. Because of this experience we recommend that following myocardial revascularization, aortic cannulation be maintained during repair of the abdominal aortic aneurysm. This allows immediate access to cardiopulmonary bypass should untoward cardiovascular events occur during aneurysm repair.     

Coronary artery bypass grafting by utilizing the artery grafts and bovine internal thoracic artery graft (Bioflow in an elderly patient)]

We performed coronary artery bypass grafting (CABG) in a 80-year-old male with calcified ascending aorta and severe varicose veins utilizing the bilateral internal thoracic arteries and the right gastroepiploic artery under fibrillatory arrest without aortic cross-clamp (aortic no-touch technique). After triple coronary artery bypass grafting was completed, heart failure occurred. Additional Bioflow graft to the circumflex artery restored good cardiac function. The aortic no-touch technique is a useful method for CABG in patients with severe calcified ascending aorta. This experience suggests that the Bioflow graft is a helpful conduit at an urgent situation in CABG.     

A case report of combined composite valve graft replacement of the aortic root and graft replacement of the abdominal aorta

A 55-year-old man who had both aortic root aneurysm with severe aortic regurgitation and enlarging abdominal aortic aneurysm was admitted to our hospital. We employed the combined composite valve graft replacement of the aortic root and Y-graft replacement of the infrarenal abdominal aorta at one stage operation. At the operation, median sternotomy was made and the composite graft replacement of the aortic root was performed under cardiopulmonary bypass prior to the abdominal procedure. After cardiopulmonary bypass was removed, abdominal incision was made. Although ventricular arrhythmias and mild hypotension transiently occurred when the abdominal aorta was clamped, the Y-graft replacement was also completed uneventfully, and no complication occurred postoperatively. We conclude that the combined operation of the aortic root and the abdominal aorta is clinically feasible in certain situation.     

Simultaneous abdominal aortic aneurysm repair during the on-pump coronary artery bypass grafting.

A case of simultaneous coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) repair on cardiopulmonary bypass (CPB) is reported. A 74-year-old man was diagnosed with left main coronary disease and infrarenal AAA. Triple CABG and infrarenal AAA repair were performed simultaneously, by different surgeons, on CPB. The duration of CPB, aortic clamp time, and total operation time was 81 min, 33 min, and 245 min, respectively. The patient was extubated three hours after ICU admission and the postoperative course was uneventful. This method is useful for reduction of operation time, for blood salvage, and for adjustment of preload and afterload of the vulnerable heart during AAA repair.     

Ascending aorta to femoral arteries bypass without opening the abdominal cavity. Choice treatment in cases of complete occlusion of the infrarenal aorta

In two cases which needed a revascularization of the inferior limbs, it was possible to utilize the subrenal aorta (the first case was affected by an infrarenal aortic occlusion; the second by an infection of a previously inserted aortofemoral graft), the AA. elected to perform a bypass with a dacron graft between the ascending aorta and femoral arteries according to the technique already proposed by Kaplitt. Having accomplished the proximal anastomoses to the ascending aorta through a midsternal incision, the graft was placed into a properitoneal tunnel down to both inguinal regions. This tunnel was obtained in the anterior abdominal wall by a blind blunt dissection entering the properitoneal space at the inferior end of the sternal incision. In this way the opening of the abdomen is avoided. On account of its poor risk, this procedure is advisable not only in cases of infrarenal aortic occlusion but almost in all aged and poor risk patients who require a revascularization of the inferior limbs.     

Total aortic arch aneurysm repair using a stent graft without cardiac or cerebral ischemia

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.