Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement

Background

Ideal perfusion during ascending aorta-arch surgery should allow easy implementation of antegrade cerebral perfusion while avoiding atheroembolization or false lumen perfusion in dissections. We report favorable experience with direct axillary artery cannulation.

Methods

Between 1999 and 2003, 284 patients with a mean age of 62.2 years (25 to 85), underwent axillary artery cannulation using a right angle wire-reinforced catheter. During this interval, attempted axillary cannulation was abandoned in only 14 patients because of inadequate backflow or other complications. Eighty-five patients were female. Severe aortic arteriosclerosis or degeneration was present in 209, aortic dissection in 63, and Marfan disease or aortitis in 12. The Bentall procedure was done in 144 patients, arch replacement in 86, the Yacoub procedure in 18, thoracoabdominal aneurysm repair in 16, and coronary artery bypass grafting in 20. Reoperations were at 30.2%.

Results

Adverse outcome (hospital death or permanent stroke) occurred in 6.6% (n = 19). Thirteen patients (4.6%) died before hospital discharge, and 13 patients (4.6%; 9 of whom died) suffered permanent stroke. Transient neurologic dysfunction occurred in 9.2% (n = 26). Mean duration of hypothermic circulatory arrest, used in 246 patients, was 26 ±7 minutes. Mean duration of antegrade cerebral perfusion, used in 139 patients, was 47 ± 23 minutes. In 93%, the right axillary artery was cannulated. Complications included 2 cases (0.7%) of brachial plexus injury (one transient), and 3 (1%) of localized dissection.

Conclusions

Our results suggest that axillary artery cannulation, successful in 95% of patients, may be the optimal technique for reducing perfusion-related morbidity and adverse outcome in operations for acute dissection, atherosclerotic, and degenerative aneurysmal disease. It deserves serious consideration in all patients older than 65 requiring cardiopulmonary bypass.     

Axillary artery cannulation for arterial inflow in patients with acute dissection of the ascending aorta.

The axillary artery is an alternative site for arterial cannulation that avoids manipulation of the ascending aorta or aortic arch and provides antegrade blood flow during surgery for acute type A aortic dissection. Right axillary artery cannulation has been used in 27 patients for arterial perfusion. There were no complications related to the technique of axillary cannulation. All patients but one awoke neurologically intact from operation and suffered no complications. Hospital mortality occurred in two (7.4%) patients. Axillary cannulation is easy to establish and may safely be used for arterial inflow during surgery for acute type A dissection of the ascending aorta.     

Direct cannulation of the common carotid artery during the ascending aortic or aortic arch replacement

Objective: To evaluate cerebral perfusion using direct cannulation into the common carotid artery. A new technique is needed to protect brain ischemic injury during ascending aortic or aortic arch replacement. Methods: This technique was evaluated for patients who would have difficulty maintaining adequate cerebral perfusion during surgery. The procedure was performed when patients had the following diagnoses: pseudoaneurysm formation in contact with the sternum with the risk of aneurysmal rupture (n=5), acute aortic dissection with compression of the true lumen of the innominate artery by the pseudolumen (n=3), or a large volume of thrombus in the lumen of the aneurysm with the risk of cerebral thromboembolism if standard extracorporeal circulation was used (n=2). The perfusion catheter was cannulated into one side of the common carotid artery (right side: n=6, left side: n=4) and mean perfusion flow rate was found to be 175 mL/min. The operative procedures consisted of ascending aortic and aortic arch replacement with coronary artery bypass grafting in six patients, ascending aortic replacement in 2 patients, and innominate artery reconstruction/innominate artery and right subclavian artery reconstruction in one patient. Results: No cerebral accidents or deaths occurred while patients were hospitalized. We have followed up patients for a mean of 2.1 years (maximum 3.6 years), with no complications noted from the surgical procedure. Conclusions: Direct cannulation of the common carotid artery is a simple, safe, and acceptable cerebral protection for patients undergoing aortic or aortic arch replacement procedures in the patients with these specific conditions.     

Axillary artery and transapical aortic cannulation as an alternative to femoral artery cannulation.

We present an experience with axillary artery and transapical aortic cannulation for cardiopulmonary bypass according to our indication. We could simply achieve antegrade flow using the two methods with satisfactory result.     

Complete thromboendarterectomy of the calcified ascending aorta and aortic arch.

BACKGROUND: Arteriosclerotic plaques of the ascending aorta and transverse arch increase the operative risk of cardiac operations and are strong predictors for late cerebrovascular events. METHODS: Twenty-two patients, mean age 68 +/- 6 years (range, 55 to 77 years), with grade IV + V plaques of the ascending aorta and transverse arch underwent coronary artery bypass grafting (n = 21) and aortic valve replacement (n = 8). Cerebrovascular emboli from unknown sources were found preoperatively in 8 patients (36%). All were in sinus rhythm. Complete thromboendarterectomy of the ascending aorta and transverse arch was performed during hypothermic circulatory arrest. After 21 +/- 12 months (range, 4 to 44 months), magnetic resonance imaging and transthoracic echocardiography of endarterectomized vessels was performed. RESULTS: There was one perioperative death (4.5%), one early (4.5%), and one late (4.7%) adverse neurologic event. Follow-up examinations revealed normal diameters of the endarterectomized aorta. CONCLUSIONS: For patients with grade IV + V plaques, thromboendarterectomy of the ascending aorta and transverse arch can be performed with an acceptable surgical risk and a low recurrence rate for cerebrovascular events. Dilatation of the endarterectomized aorta was not observed.     

Axillary artery cannulation in type a aortic dissection operations.

BACKGROUND: Femoral arteries are the preferred site of peripheral cannulation for arterial inflow in type A aortic dissection operations. The presence of aortoiliac aneurysms, severe peripheral occlusive disease, atherosclerosis of the femoral vessels, and distal extension of the aortic dissection may preclude their utilization. Axillary artery cannulation may represent a valid alternative in these circumstances. METHODS: Between January 15, 1989, and August 20, 1998, in our institution, 22 of 152 operations (14.4%) for acute type A aortic dissection were performed with the use of the axillary artery for the arterial inflow. Axillary artery cannulation was undertaken in the presence of femoral arteries bilaterally compromised by dissection in 12 patients (54.5%), abdominal aorta and peripheral aneurysm in 5 patients (22.7%), severe atherosclerosis of both femoral arteries in 3 patients (13. 6%), and aortoiliac occlusive disease in 2 patients (9.1%). In all patients, distal anastomosis was performed with an open technique after deep hypothermic circulatory arrest. Retrograde cerebral perfusion was used in 9 patients (40.9%). RESULTS: Axillary artery cannulation was successful in all patients. The left axillary artery was cannulated in 20 patients (90.9%), and the right axillary artery was cannulated in 2 patients (9.1%). Axillary artery cannulation followed an attempt of femoral artery cannulation in 15 patients (68. 2%). All patients survived the operation, and no patient had a cerebrovascular accident. No axillary artery thrombosis, no brachial plexus injury, and no intraoperative malperfusion were recorded in this series. Two patients (9.1%) died in the hospital of complications not related to axillary artery cannulation. CONCLUSIONS: In patients with type A aortic dissection in whom femoral arteries are acutely or chronically diseased, axillary artery cannulation represents a safe and effective means of providing arterial inflow during cardiopulmonary bypass.     

Safe cannulation of the ascending aorta.

Numerous complications have been reported secondary to cannulation of the ascending aorta. This report describes our technique of cannulating the ascending aorta and presents the results of this safe mode of perfusion in 684 consecutive patients.     

Brain protection by using innominate artery cannulation during aortic arch surgery

The innominate artery cannulation (IAC) through the same sternotomy incision was used for 68 patients with aneurysm, involving the ascending aorta or the aorta arch. The IAC can get adequate flows during cooling and re-warming of cardiopulmonary bypass. It can also provide sufficient antegrade perfusion for brain during hypothermia circulation arrest. There is no relative complication noted for the technique, and we believe it is a simple and effective alternative.     

升主动脉和弓部动脉瘤的外科治疗

目的：总结升主动脉和弓部动脉瘤手术治疗经验，以期进一步提高手术疗效。方法：自2000年7月至2002年5月应用深低温停循环（DHCA）和上腔静脉逆行脑灌注（RCP）技术手术治疗升主动脉和弓部动脉瘤20例，其中急症手术5例。施行全弓置换术2例，全弓置换和象鼻手术3例，半弓置换术15例。同期行Bentall手术8例，升主动脉置换术或同时行主动脉瓣置换术12例，冠状动脉旁路移植术1例。结果：术后早期死亡1例，短时间浅昏迷1例，呼吸功能不全2例，肾功能不全2例，无晚期死亡。结论：DHCA和RCP技术是手术治疗升主动脉和弓部瘤的安全、有效方法，急性A型夹层动脉瘤的手术方式取决于内膜破裂口的位置；正确掌握DHCA和RCP技术，手术方式和手术技术、围术期处理是提高手术疗效的关键因素。     

Transposition of the left carotid artery to the ascending aorta to repair aortic arch injury

Abstract   We present a case where we repaired the aortic arch, by the transposition of the left carotid artery to the ascending aorta. A 52-year-old man presented to our department with a penetrating chest wound by a gunshot in the attempt of suicide. The aortic arch and the insertion of the left carotid artery were involved in the lesion. Through sternotomic approach, the aortic arch was repaired in extracorporeal circulation. Left carotid artery was transected to allow easier repair of the arch posterior wall involved in the lesion, and to reduce the danger of residual stenosis. Then, it was translocated to the ascending aorta by interposing a 7-mm Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ, USA) conduit. The patient complicated renal failure and pneumonia in the postoperative period, but eventually he was discharged in good general conditions.     

Sutureless ring graft replacement of ascending aorta and aortic arch

Complications after aortic replacement that result from prolonged graft insertion time and technical difficulties with suturing through friable, diseased aortic tissue can be addressed with use of the sutureless intraluminal ring graft. Between 1978 and 1989, we replaced the ascending aorta or aortic arch with this device in 49 patients. At no time were we unable to use a sutureless graft during a procedure. Twenty-eight cases of aneurysmal disease and 21 cases of acute or chronic dissection were treated. Twenty-six patients required replacement of the aortic valve, with annuloartic ectasia being the most common indication (71%). Ten patients underwent concomitant coronary artery bypass grafting. The operative mortality rate for ascending aortic aneurysm repairs was 4%, and that for dissections was 18%. Five of 8 patients requiring aortic arch replacement survived. Most patients were studied angiographically before discharge. No complications were related to anastomotic hemorrhage, pseudoaneurysm formation, graft migration, or thromboemboli. Individual cases of phrenic nerve palsy, acute tubular necrosis, and transient ischemic attack, all of which resolved completely, were identified. The actuarial 5-year survival rate is 64%. We conclude that modification of the sutureless intraluminal ring graft to suit the pathology encountered at operation allows the quickest repair with the least chance of anastomotic complication.     

Minimized mortality and neurological complications in surgery for chronic arch aneurysm: axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and total arch aorta

OBJECTIVE: Cerebral complication is still a major concern in surgery for arteriosclerotic aortic arch disease. For preventing this complication, axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and arch aorta were applied to thoracic aortic aneurysm involving aortic arch. METHOD: From May 1999 to July 2002, consecutive 39 patients with true aneurysm (29 patients) or chronic aortic dissection (10 patients) involving aortic arch underwent replacement of the ascending and arch aorta with an elephant trunk under hypothermic cardiopulmonary bypass through the axillary artery cannulation and selective cerebral perfusion. The brain was continuously perfused without any intermission through the axillary artery. Concomitant operation included coronary artery bypass grafting (CABG) in two patients, aortic valve replacement (AVR) in one, Bentall operation in two, mitral valve replacement (MVR) in one, and aortic valve sparing operation in one. Patient age at operation was 40-84 (72 + 9) years and 24 of them were older than 70 years of age. RESULTS: There was one operative death (2.5%) due to bleeding from the left lung, and one hospital death due to respiratory failure. Postoperative permanent neurological dysfunction was found in one patient (2.5%). Two patients presented temporary neurological dysfunction (5%). Thirty-six of the 39 patients were discharged from hospital on foot. CONCLUSION: Continuous perfusion through the axillary artery with selective cerebral perfusion and replacement of the ascending and arch aorta may minimize cerebral complication leading to satisfactory results in patients with chronic aortic aneurysm involving aortic arch.     

Complications of cannulation of the ascending aorta for open heart surgery

In a series of 420 ascending aortic cannulations for cardiopulmonary bypass, major complications occurred in three patients. Aortic dissection occurred in one patient believed to be due to aortic cross-clamping. Avoidance of this manœuvre is suggested when the aorta is grossly atheromatous. Two patients developing false aneurysms due to mediastinal infection are described. Prevention of mediastinal infection and its treatment are discussed. The method of treatment of false aneurysms by deep hypothermia is described.