Abstract OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. Axillary artery cannulation, Open Seldinger-guided technique, Peripheral cannulation for cardiopulmonary bypass INTRODUCTION In our institution, the femoral artery is the preferred site for peripheral cannulation in thoracic aortic surgery [1–3]. However, right axillary cannulation is utilized when the thoraco-abdominal aorta contains atheromas or other potential sources of embolization. These may be detected on the preoperative computed tomography scan or intraoperative transoesophageal echocardiography. Other reasons for axillary cannulation include peripheral vascular disease in the iliofemoral system and extreme obesity. The use of a side graft in the axillary cannulation has been recommended instead of a classic incision technique (in which the axillary artery is snared for the insertion of the cannula and the vessel is distally occluded by the cannula itself), because it was associated with reduction of the cannulation-related morbidity . Since 2011, we have routinely used an open Seldinger-guided approach for axillary artery cannulation without sidearm graft, arterial incision or distal vessel clamping during perfusion. The purpose of this report is to evaluate the safety and effectiveness of this technique. MATERIALS AND METHODS Study design This study was performed under the Human Investigation Committee protocol for clinical research with the database of the Aortic Institute at Yale-New Haven Hospital. We retrospectively analysed our institutional database from March 2011 to September 2016 to find all cases of peripheral cannulation for thoracic aortic surgery. Medical charts were then reviewed for cannulation site, operative procedure and postoperative course. We paid particular attention to complications potentially related to axillary cannulation, including intraoperative local arterial injury (dissection or rupture), malperfusion phenomena, postoperative limb ischaemia, brachial plexus injury, wound infection, stroke and death. Postoperative follow-up visits were also analysed to evaluate late wound infections and pseudoaneurysms. Surgical technique Normally, arterial pressure is measured with a left radial or brachial artery cannula, so that the right axillary artery can be cannulated. However, for elephant trunk procedures, we usually perform the distal anastomosis proximal to the left subclavian artery. The left subclavian artery is then managed with a small diameter graft during rewarming or later during Stage 2. Consequently, in these cases, we routinely measure arterial pressure in the right common femoral artery. Before median sternotomy, a 4–6-cm incision is made inferior to the middle part of the right clavicle. The pectoralis major muscle is divided and then retracted perpendicular to the direction of its fibres. The clavipectoral fascia is then incised. The underlying pectoralis minor is retracted laterally or incised. Using sharp dissection, the artery is isolated from the surrounding tissue. Great care is taken to avoid injury to the brachial plexus. The vessel is controlled with loops of silicone elastomer tape. A single purse-string suture is placed on the artery using 5-0 Prolene. After administration of heparin, an 18-G needle is inserted in the middle of the purse string, through which a 0.038-inch guidewire is advanced into the descending thoracic aorta, as confirmed by transoesophageal echocardiography. We use a 16–20-Fr FemFlex II arterial cannula (Edwards Lifesciences, Irvine, CA, USA). The size of the cannula is based on the patient’s body surface area (BSA): 16 Fr for BSA less than 1.6, 18 Fr for BSA 1.7–2.0 and 20 Fr for BSA greater than 2.0. With these sizes, we easily obtain flows in excess of 4 l/min. The FemFlex II arterial cannula can accommodate a guidewire. After the needle is removed, the dilators and subsequently the FemFlex arterial cannula are advanced over the guidewire. The internal dilator is then removed, the cannula is connected to the arterial circuit, the purse string is cinched down (Fig. 1) and the cannula secured to the snare. When the patient is weaned from cardiopulmonary bypass, the cannula is removed and the purse string is simply tied without clamping the vessel. We uniformly place a mattress 5-0 Prolene stitch over the top of the purse string for added security. The right axillary pulse is then checked distal to the purse string. Figure 1: View largeDownload slide (Bottom) The axillary artery after the dissection, and (top) the guidewire and the cannula inside the purse string. Figure 1: View largeDownload slide (Bottom) The axillary artery after the dissection, and (top) the guidewire and the cannula inside the purse string. In our institution, for procedures on the aortic arch, we exclusively use straight deep hypothermic circulatory arrest (DHCA) [5–7]. The patient is cooled to a level at which the bladder temperature reaches 18°C. The patient’s head is routinely packed with ice. No cerebral oximetry or electroencephalogram monitoring is used. Steroids are routinely administered for all patients before cardiopulmonary bypass is initiated, and alpha-stat management is used for acid–base balance. Rewarming is always performed slowly (gradient between blood and bath temperature <10 °C) to prevent protein denaturation . RESULTS Patients We identified 404 consecutive patients who underwent peripheral arterial cannulation. Of these, 352 were femoral and 52 were axillary cannulations. All axillary cases were for ascending and/or arch surgery. Cannulation was successfully achieved in all patients using this technique. Median age was 71 (range 47–88) years and 65.3% (34 of 52) were men. The indication for surgery was aneurysm in 63.5% (33/52), dissection (acute or chronic) in 30.7% (16/52) and pseudoaneurysm in 5.8% (3/52). Thirty-five (67.3%) procedures were performed electively, 11 were urgent (21.2%) and the remaining 6 (11.5%) were emergent. A redo sternotomy was done in 10 of 52 (19.2%) patients. In 44 (84.6%) patients, a procedure on the aortic arch was carried out: a deep hemiarch replacement in 20 (38.4%) patients and a formal arch replacement with Stage 1 elephant trunk in 24 (46.1%) patients. Outcomes The in-hospital mortality was 1.9% (1 of 52). There was no instance of intraoperative local arterial injuries, dilator-related issues and malperfusion phenomena during cardiopulmonary bypass. No cases of postoperative limb ischaemia or stroke were recorded. There were no cases of early or late wound infection. Only 1 (1.9%) patient exhibited a clinical scenario suggestive of a brachial plexus injury. In this patient, a transitory numbness of the medial aspect of the right hand was present at discharge, but the symptoms resolved by the time of the follow-up visit 1 month after operation. There were no cases of late pseudoaneurysm at the cannulation site. DISCUSSION The arterial inflow site for cardiopulmonary bypass has varied over the last 5 decades. In the early days of cardiac surgery, the femoral artery was routinely used , before being superseded by the distal ascending aorta [10, 11]. Although distal ascending aortic cannulation is undoubtedly the safest and the most expedient site for arterial inflow, debate continues regarding the optimal cannulation site when the ascending aorta is unsuitable. Direct axillary cannulation was first described in 1976 by Villard et al.  but was subsequently utilized only rarely. In the second half of the 1990s, the Cleveland Clinic group published a series of 35 patients  in whom direct axillary cannulation was used because of extensive atherosclerotic disease. Since then many reports on improved neurocognitive outcomes with axillary cannulation have made this approach increasingly popular [4, 14, 15]. In our institution, the femoral artery remains our preferred cannulation site for aortic surgery. In 2011, we published our experience with 767 consecutive patients who underwent femoral cannulation for thoracic aortic surgery . This experience demonstrated excellent survival, low stroke rates and minimal perfusion-related ruptures or dissections. In selected cases where retrograde perfusion is contraindicated due to atherosclerosis of the aortoiliac system, we use axillary cannulation. The relatively small diameter of the axillary artery and its delicacy are potentially associated with higher risk of arterial injury and malperfusion phenomena. These characteristics, together with the lower incidence of stroke  relative to the classical incision technique, have made the side graft technique preferred in many centres. However, the use of side graft is contraindicated in cases of haemodynamic instability, because it is more time-consuming. Moreover, the sidearm anastomosis tends to bleed during the bypass time. The sidearm needs to be closed after the bypass is concluded. A permanent graft remains indefinitely. Open Seldinger-guided axillary cannulation avoids these drawbacks simply and completely. Limitations When discussing the study limitations, it is important to note that this report is not intended to compare the different techniques for axillary artery cannulation or to compare femoral with axillary cannulation. This is an observational study, and our target is simply to demonstrate the safety and effectiveness of the open Seldinger-guided technique for axillary cannulation. CONCLUSION This report demonstrates that the open Seldinger-guided technique for the axillary cannulation is safe and effective. This technique is faster than the side graft technique, and manipulation of the vessel is minimized. The use of the open Seldinguer-guided technique decreases the operation time. The vessel is not snared, thereby reducing the risk of limb ischaemia. We recommend Seldinger-guided axillary cannulation over the sidearm or incision technique for its rapidity, simplicity and effectiveness. Conflict of interest: none declared. REFERENCES 1 Ayyash B, Tranquilli M, Elefteriades JA. Femoral artery cannulation for thoracic aortic surgery: safe under transesophageal echocardiographic control. J Thorac Cardiovasc Surg 2011; 142: 1478– 81. Google Scholar CrossRef Search ADS PubMed 2 Fusco DS, Shaw RK, Tranquilli M, Kopf GS, Elefteriades JA. Femoral cannulation is safe for type A dissection repair. Ann Thorac Surg 2004; 78: 1285– 9; discussion 85–9. Google Scholar CrossRef Search ADS PubMed 3 Tsiouris A, Elkinany S, Ziganshin BA, Elefteriades JA. Open Seldinger-guided femoral artery cannulation technique for thoracic aortic surgery. Ann Thorac Surg 2016; 101: 2231– 5. Google Scholar CrossRef Search ADS PubMed 4 Sabik JF, Nemeh H, Lytle BW, Blackstone EH, Gillinov AM, Rajeswaran J et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004; 77: 1315– 20. Google Scholar CrossRef Search ADS PubMed 5 Ziganshin BA, Rajbanshi BG, Tranquilli M, Fang H, Rizzo JA, Elefteriades JA. Straight deep hypothermic circulatory arrest for cerebral protection during aortic arch surgery: safe and effective. J Thorac Cardiovasc Surg 2014; 148: 888– 98; discussion 898–900. Google Scholar CrossRef Search ADS PubMed 6 Chau KH, Friedman T, Tranquilli M, Elefteriades JA. Deep hypothermic circulatory arrest effectively preserves neurocognitive function. Ann Thorac Surg 2013; 96: 1553– 9. 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Superiority of aortic over femoral cannulation for cardiopulmonary bypass, with specific attention to lower extremity neuropathy. J Cardiovasc Surg (Torino) 1978; 19: 277– 9. Google Scholar PubMed 12 Villard J, Froment JC, Milleret R, Dureau G, Amouroux C, Boivin J et al. [Type I, complete, acute aortic dissection. Value of arterial perfusion by the axillary route (author’s transl)]. Ann Chir Thorac Cardiovasc 1976; 15: 133– 5. Google Scholar PubMed 13 Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995; 109: 885– 90; discussion 890–1. Google Scholar CrossRef Search ADS PubMed 14 Svensson LG, Blackstone EH, Rajeswaran J, Sabik JF3rd, Lytle BW, Gonzalez-Stawinski G et al. Does the arterial cannulation site for circulatory arrest influence stroke risk? Ann Thorac Surg 2004; 78: 1274– 84; discussion 1274–84. Google Scholar CrossRef Search ADS PubMed 15 Strauch JT, Spielvogel D, Lauten A, Lansman SL, McMurtry K, Bodian CA et al. Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement. Ann Thorac Surg 2004; 78: 103– 8; discussion 103–8. Google Scholar CrossRef Search ADS PubMed © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Journal of Cardio-Thoracic Surgery – Oxford University Press
Published: Nov 20, 2017
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