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Ann Thorac Surg 1997;63:253-254
© 1997 The Society of Thoracic Surgeons

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How To Do It

Forty-Five--Degree Two-Stage Venous Cannula: Advantages Over Standard Two-Stage Venous Cannulation

Department of Cardiothoracic Surgery, King's College Hospital, London, United Kingdom

Accepted for publication August 1, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Comment Acknowledgments Reference

 
We present a 45-degree two-stage venous cannula that confers advantage to the surgeon using cardiopulmonary bypass. This cannula exits the mediastinum under the transverse bar of the sternal retractor, leaving the rostral end of the sternal incision free of apparatus. It allows for lifting of the heart with minimal effect on venous return and does not interfere with the radially laid out sutures of an aortic valve replacement using an interrupted suture technique.

	Introduction

Top Footnotes Abstract Introduction Technique Comment Acknowledgments Reference

 
Bugge and associates [1] described a "90-degree bent" two-stage venous cannula with several advantages over the straight two-stage cannula used in routine cardiopulmonary bypass. We too have found that the straight two-stage venous cannula has a tendency to decrease venous return and increase the central venous pressure when the heart is displaced for exposure of its inferior surface. The straight cannula loops over the right side of the chest and thus takes a longer path back to the venous reservoir of the cardiopulmonary bypass machine. Consequently, there is increased risk of line kinking and obstruction of venous return.

Because we have designed our cannula to match the exact contour it requires to function without stressing the right atrium, we think it is an improvement on the "90-degree bent" version. We believe it should decrease septal distortion, atrial tears, and the generation of arrhythmias.

	Technique

Top Footnotes Abstract Introduction Technique Comment Acknowledgments Reference

 
We commenced using this cannula in 1991 and have used it in more than 800 cases of cardiopulmonary bypass. The cannula is bent in a J-type fashion to an angle of 45 degrees. It has two stop marks around the bend to mark the level of insertion. The bend, like the rest of the flexible tube, is reinforced with coiled wire and does not kink. The tube is a standard 51F size. The proximal set of circumferential ports are 3 cm distal to the bend and designed to lie in the right atrium. The distal set of ports are a further 8 cm away. The two sets of ports are connected by a 36F steel wire-reinforced tube, which is particularly flexible (Fig 1).

View larger version (75K): [in this window] [in a new window]   Fig 1. . The 45-degree two-stage cannula.

View larger version (17K): [in this window] [in a new window]   Fig 2. . Saggital view of the cannula in place.

View larger version (123K): [in this window] [in a new window]   Fig 3. . The cannula ready for use.

	Comment

Top Footnotes Abstract Introduction Technique Comment Acknowledgments Reference

Second, it leaves the right side of the chest free of tubing, which could get in the way of either the operator's hands or the sutures of an aortic valve replacement by interrupted suture technique. Attempted adjustments of the venous cannula with the sutures radially laid out is cumbersome and time-consuming.

Third, the fact that this cannula passes under the transverse bar of the sternal retractor enables the operator to have a free cranial end of the sternotomy incision that is free of metalwork. There is therefore no interference with the aortic cannula, and it clears the area for preparation of the distal ends of the internal thoracic arteries and the aorto-conduit anastamoses. The former point is particularly important to us as we currently use bilateral internal thoracic arteries in 83.5% of our coronary artery bypass procedures, and the risk of having the ratchet of the sternal retractor at the cranial end of the incision is unnecessary. We believe this is an important advantage over the 90-degree cannula.

Finally, as this cannula closely fits the shape of the right atrium and inferior vena cava, it is less likely to traumatize these structures than the 90-degree version. Trauma to the right atrium can result in air entering the venous circuit and interruption of extracorporeal circulation. Because there is less distortion of the septum, the generation of arrhythmias is less likely.

We have noted two difficulties that may be experienced with initial use of the cannula. First, when the proximal right coronary artery is being grafted the cannula will appear to lie directly in the path of the surgeon's view. We overcome this by pushing the cannula over to the left side of the wound, where it is anchored with a silk tie. This gives good exposure and overcomes the problem easily.

The second problem we have encountered is a consequence of the fact that the right atrium is maintained in its anatomic position when our cannula is used. Because it does not lift up the right atrium like its straight counterpart, we have encountered some difficulty with positioning of retrograde cardioplegia cannulas. This may be overcome by partial venous occlusion and is not currently a major problem.

With the two exceptions noted above, we have not experienced any disadvantage of the cannula. In particular, air locks have not been a problem in that they are rare and easily rectified by adjusting the position of the venous line on the patient's abdomen. The cannula can be clamped and the venous line refilled should this become necessary.

This cannula, like the 90-degree version, is cheap and easy to insert. In our opinion this cannula, by freeing up even more space on the operating field, has made cardiopulmonary bypass a little easier and quicker to perform.

	Acknowledgments

Top Footnotes Abstract Introduction Technique Comment Acknowledgments Reference

 
The cannula is made by Research Medical, Midvale, UT. It is marketed in the United Kingdom by Somatech Medical Ltd, 3 Station Rd, Chinnor, Oxford OX9 4PU, England; telephone +44 184 435 2220. Quote code SPC-652.

	Footnotes

Top Footnotes Abstract Introduction Technique Comment Acknowledgments Reference

 
Address reprint requests to Dr Lawrence, c/o Dr J. B. Desai, Department of Cardiothoracic Surgery, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom (e-mail: drl{at}romesh.demon.co.uk).

	Reference

Top Footnotes Abstract Introduction Technique Comment Acknowledgments Reference

 

1. Bugge M, Lepore V, Dahlin A. The "90 degree bent" two-stage venous cannula. Eur J Cardiothorac Surg 1995;9:526–7.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David R. Lawrence Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lawrence, D. R. Articles by Desai, J. B. Search for Related Content PubMed PubMed Citation Articles by Lawrence, D. R. Articles by Desai, J. B.