HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Sary F. Aranki Gregory S. Couper David H. Adams Robert J. Rizzo John J. Collins, Jr Lawrence H. Cohn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bichell, DavidP. Articles by Cohn, L. H. Search for Related Content PubMed PubMed Citation Articles by Bichell, DavidP. Articles by Cohn, L. H.

Ann Thorac Surg 1997;64:702-705
© 1997 The Society of Thoracic Surgeons

---

Original Article: Cardiovascular

Axilloaxillary Cardiopulmonary Bypass: A Practical Alternative to Femorofemoral Bypass

Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

Accepted for publication March 27, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Peripheral arterial and venous cannulation for cardiopulmonary bypass is used increasingly for patients undergoing minimally invasive cardiac operations, complex reoperations, or repair of aortic dissection or aneurysm, and for patients with extensive arteriosclerotic aortic disease in whom aortic cannulation is a prohibitive embolic risk. The common femoral artery and vein are most commonly used for peripheral cannulation, but these sites may be predisposed to complications, primarily because the femoral vessels are commonly involved with arteriosclerotic disease. We have recently begun to use the axillary artery and axillary vein as alternative cannulation sites, achieving full cardiopulmonary bypass, providing antegrade aortic flow, and avoiding many of the complications associated with other sites.

Methods. Seven patients with peripheral vascular or aortic disease, or both, prohibiting safe aortic or femoral cannulation underwent cardiopulmonary bypass through axillary artery and axillary vein cannulation, approached through a small single subclavicular incision.

Results. All patients were successfully cannulated and axilloaxillary cardiopulmonary bypass was possible without the need for additional cannulas. All axillary vessels were closed primarily without complication.

Conclusion. For an expanding population of patients with peripheral vascular and aortic disease, axilloaxillary bypass is a safe and practical alternative to aortic or femoral cannulation.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Cardiopulmonary bypass (CPB) may be initiated from a peripheral cannulation site in patients undergoing cardiac and aortic procedures when CPB is required before sternotomy or thoracotomy, and in patients for whom aortic disease precludes the safe cannulation of the aorta [1–4]. The recent advent of minimally invasive valve and coronary surgery has further expanded the list of indications for peripheral CPB cannulation because of space limitation in the operative site. The common femoral artery and vein have been the standard peripheral cannulation sites, but these sites present some risk, especially from arteriosclerotic arterial obstruction. Axillary artery cannulation in conjunction with femoral vein or right atrial cannulation has been described for CPB in the patient with prohibitive severe arteriosclerotic femoral arteries or ascending aortic disease [5–7]. We report our experience with axillary artery and axillary vein cannulation through a small single subclavicular incision, achieving excellent decompression of the heart and flows in excess of 3 L/min in situations in which peripheral cannulation is either extremely desirable or mandatory.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Patients
Seven patients underwent combined axillary vessel cannulation. The patients ranged from 63 to 80 years of age; 5 were male and 2 were female (Table 1). Six of the 7 patients had severe peripheral vascular disease and one had severe ascending aortic disease. Two underwent reoperative coronary artery bypass grafting, 2 were operated on for aortic valve replacement after previous coronary artery bypass grafting, 1 for ascending aortic replacement with reoperative coronary artery bypass grafting, 1 for aortic arch replacement for aneurysm and atheromatous emboli, and 1 for reoperative mitral valve replacement.

Axillary cannulation was chosen over femoral sites in 4 of 7 patients to avoid insult to femoral and lower extremity vessels known to be arteriosclerotic. Patients with poor or absent distal pulses, chronic changes on examination consistent with arterial occlusive disease, claudication, or previous lower extremity revascularizations were judged risky candidates for femoral artery cannulation. Axillary vessel cannulation was chosen over femoral in 3 of 7 patients to avoid retrograde flow through a diseased thoracic aorta, abdominal aorta, or iliac arteries that threatened poor flow or retrograde embolic risk. Aortoiliac disease was determined on the basis of severe aortoiliac irregularity by bifurcation views on coronary angiograms or previous peripheral angiograms. Ascending aortic disease was diagnosed by angiogram, transthoracic echocardiogram, or intraoperative transesophageal echocardiogram. Loose proximal descending aortic debris was imaged by echocardiogram and computed tomography in 1 patient with an arch aneurysm and a history of an atheroembolic stroke.

Methods
A 4- to 8-cm subclavicular incision is made at midclavicle (Fig 1). Parallel pectoralis major fibers are separated to expose the subclavicular space. The axillary vein at its junction with the cephalic vein is readily identified and mobilized superficially, sometimes requiring the mobilization or division of some lateral pectoral nerve branches (Fig 1A). The axillary vein is retracted cephalad to gain access to the deeper subclavicular space. The axillary artery is identified by palpation and is mobilized from its loose investing fascia, without touching the medial and lateral brachial plexus cords (Fig 1B). Systemic heparin is given. The artery is clamped at either end of the exposed segment and a transverse arteriotomy is made. A 5-0 Prolene (Ethicon, Somerville, NJ) pursestring is placed surrounding the arteriotomy and a tourniquet applied. A 20F or 22F Sarns flexible arterial cannula (3M, Ann Arbor, MI) is introduced and advanced 2 to 3 cm into the artery as the proximal clamp is removed (Fig 1C). The tourniquet is secured, the distal clamp removed, and the cannula secured to tourniquet and skin after connecting it to the CPB pump tubing circuit. Attention is then focused on the axillary vein, which lies superficial to the artery, and is easily accessible with the arterial cannula in place. A 5-0 Prolene longitudinal elliptical pursestring is placed at the cephalic vein–axillary vein junction. The mobilized segment of vein is clamped distally, a longitudinal venotomy is made within the pursestring, and a 25F or 27F Biomedicus venous femoral cannula and introducer (Medtronic-Biomedicus, Inc, Eden Prarie, MN) is advanced over a wire to 20 cm (Fig 1D). Venous cannula position within the right atrium is confirmed by transesophageal echocardiogram. The tourniquet is secured, introducer and clamps are removed, and connection to the inflow circuit of the CPB pump is made. At decannulation, the venous cannula is removed and the purse string tied. Arterial decannulation is performed with a reclamping of the vessel, removal of the pursestring, and primary closure of the arteriotomy using 6-0 Prolene suture.

View larger version (29K): [in this window] [in a new window]   Fig 1. . Diagram of axillary artery and axillary vein cannulation with median sternotomy. (A) Axillary vein exposure. (B) Axillary artery exposure. (C) Axillary artery cannulation. (D) Axillary vein cannulation. (R.A. =right atrium.)

View larger version (58K): [in this window] [in a new window]   Fig 2. . Axillary artery and vein anatomy for cannulation during performance of a thoracic aortic operation through a left thoracotomy.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

There were no serious complications referable to the arm and its neurovascular structures. Two patients experienced a transient brachial plexus neuropathy resulting in right hand weakness that resolved before discharge. All patients achieved full CPB with flows in excess of 3 L/min without difficulty. All axillary arteriotomies were closed primarily, without the need for thrombectomy or reconstruction. No ischemic upper extremities or compartment syndromes were noted. One patient died of renal failure and stroke after reoperation coronary artery bypass grafting and ascending aortic replacement for a "porcelain" aorta.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Arteriosclerotic disease in the aorta can present a prohibitive risk of embolization or dissection of the ascending aorta at cannulation [8–11], and has prompted the development of techniques to detect safe cannulation sites on the diseased aorta [12–14] or to the abandonment of aortic cannulation altogether in favor of femoral cannulation for CPB.

Arteriosclerotic disease in the aortoiliac and femoral systems may render common femoral artery cannulation unsuccessful altogether, or complicated by the need for patch angioplasty, endarterectomy, or thrombectomy on decannulation. Lower extremity ischemia, compartment syndrome, neurologic injury, and wound complications such as lymphocele or infection further complicate the use of the groin site for CPB cannulation [15, 16]. Propagating retrograde dissection, or the dislodgement and retrograde embolization of luminal debris, can result in ischemic end-organ injury such as stroke, renal failure, and mesenteric ischemia [17, 18].

Common femoral vein cannulation can be complicated by an inability to negotiate the cannula successfully across its long course to the right atrium, pelvic venous injury, and retroperitoneal bleeding, and is contraindicated in the presence of an inferior vena cava filter, deep venous thrombosis, or other intrinsic or extrinsic obstruction to the pelvic veins or inferior vena cava.

The axillary artery is an established alternative cannulation site [5–7]. Even in a setting of extensive aortic and innominate artery disease, the axillary artery is rarely affected and provides an excellent site for safe antegrade aortic perfusion, which may play a role in preventing embolic stroke [19]. In contradistinction to the femoral vessels, the axillary vessels enjoy rich collateralization from the thyrocervical trunk to the suprascapular and transverse cervical arteries, allowing near or total occlusion of the axillary artery to be performed without the threat of upper extremity ischemia or reperfusion injury.

A proximal cannulation site along the axillary artery, near the axillary artery–subclavian artery junction, provides the passage of a 20F to 22F arterial cannula at a location where the cords of the brachial plexus are coursing posteriorly and are not in close proximity to the artery. A synthetic graft-to-artery anastomosis with graft cannulation has been described, but this technique was not performed in this series, as direct arterial cannulation was straightforward in every case, and the additional needle trauma to the artery, potential leak, or graft kinking was avoided. The vein at this level admits the passage of a 25F to 27F venous cannula. A longitudinally placed elliptical pursestring at the junction of the cephalic and axillary veins can be closed at decannulation without narrowing the vein.

An additional advantage of axillary vein cannulation is that retrograde cerebral perfusion can be administered during circulatory arrest by pulling the venous cannula into the superior vena cava, clamping the superior vena cava below, and perfusing the venous cannula with cerebroplegia.

Femoral cannulation site wound healing can be problematic in the immunocompromised, malnourished, vasculopathic, obese, or diabetic patient, and can inhibit early ambulation and physical therapy. In complicated reoperative cardiac transplantation requiring peripheral cannulation, femoral cannulation site lymphocele with chronic drainage is a common complication, prompting this institution to prefer the axillary site in this setting. The axillary cannulation site incision does not cross a joint, is covered by pectoralis muscle on closure, and heals well without impeding ambulation.

In conclusion, the list of indications for peripheral cannulation for CPB is expanding as complex reoperations and minimally invasive operations become more common. Axillary artery and vein cannulation for peripheral cardiopulmonary bypass is a safe and effective alternative to femorofemoral bypass in the patient with prohibitive aortic or peripheral vascular disease, in situations where antegrade flow is desirable, or where wound healing capacity is depressed.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Cohn LH, Peigh PS, Sell J, DiSesa VJ. Right thoracotomy, femoro-femoral bypass, and deep hypothermia for re-replacement of the mitral valve. Ann Thorac Surg 1989;48:69–71.[Abstract]
2. Berger RL, Saini VK, Dargan EL. Clinical applications of femoral vein-to-artery cannulation for mechanical cardiopulmonary support and bypass. Ann Thorac Surg 1973;15:163–9.[Medline]
3. Pillai R, Venn G, Lennox S, Paneth M. Elective femoro-femoral bypass for operations on the heart and great vessels. J Thorac Cardiovasc Surg 1984;88:635–7.[Abstract]
4. Knight JL, Cohn LH. Left thoracotomy and femoro-femoral bypass for re-operative revascularization of the posterior coronary circulation. J Card Surg 1987;2:343–9.[Medline]
5. Villard J, Froment JC, Milleret R, et al. Type I, complete acute aortic dissection. Value of arterial perfusion by the axillary route. Ann Chir Thorac Cardiovasc 1976;15:133–5.[Medline]
6. Borst HG. Axillary artery for extracorporeal circulation [Letter]. J Thorac Cardiovasc Surg 1995;110:1775.[Free Full Text]
7. 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;109:885–91.[Abstract]
8. Reinke RT, Harris RD, Klein AJ, Daily PO. Aortoiliac dissection due to aortic cannulation. Ann Thorac Surg 1974;18:295–9.[Medline]
9. Gardner TJ, Horneffer PJ, Manolio TA, et al. Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 1985;40:574–81.[Abstract]
10. Salama FD, Blesovsky A. Complications of cannulation of the ascending aorta for open heart surgery. Thorax 1970;25:604–7.[Abstract/Free Full Text]
11. Blauth CI, Cosgrove DM, Webb BW, et al. Atheroembolism from the ascending aorta: an emerging problem in cardiac surgery. J Thorac Cardiovasc Surg 1992;103:1104–12.[Abstract]
12. Wareing TH, Davila-Roman VG, Barzolai B, Murphy SF, Kouchoukos NT. Management of the severely atherosclerotic ascending aorta during cardiac operations: a strategy for detection and treatment. J Thorac Cardiovasc Surg 1992;103:453–62.[Abstract]
13. Marshall WG, Barzolai B, Kouchoukos NT, Saffitz J. Intraoperative ultrasonic imaging of the ascending aorta. Ann Thorac Surg 1989;48:339–44.[Abstract]
14. Golding LA. New cannulation technique for the severely calcified ascending aorta. J Cardiovasc Surg 1985;90:626–7.
15. Serry C, Najafi H, Dye WS, Javid H, Hunter JA, Goldin MD. Superiority of aortic over femoral cannulation for cardiopulmonary bypass, with specific attention to lower extremity neuropathy. J Cardiovasc Surg (Torino) 1978;19:277–9.[Medline]
16. Gates JD, Bichell DP, Rizzo RJ, Couper GS, Donaldson MC. Thigh ischemia complicating femoral vessel cannulation for cardiopulmonary bypass. Ann Thorac Surg 1996;61:730–3.[Abstract/Free Full Text]
17. Eugene J, Aronow WS, Stemmer EA. Retrograde aortic dissection during cardiopulmonary bypass. Clin Cardiol 1981;4:356–9.[Medline]
18. Tanemoto K, Kuinose M, Kanaoka Y. Complications of femoral artery cannulation in aortic arch related operations. Nippon Kyobu Geka Gakkai Zasshi 1994;42:306–10.[Medline]
19. Kouchoukos NT. Adjuncts to reduce the incidence of embolic brain injury during operations on the aortic arch. Ann Thorac Surg 1994;57:243–5.[Abstract]

This article has been cited by other articles:

				C. D. Etz, K. A. Plestis, F. A. Kari, D. Silovitz, C. A. Bodian, D. Spielvogel, and R. B. Griepp Axillary cannulation significantly improves survival and neurologic outcome after atherosclerotic aneurysm repair of the aortic root and ascending aorta. Ann. Thorac. Surg., August 1, 2008; 86(2): 441 - 446. [Abstract] [Full Text] [PDF]

				J. W. Hammon Extracorporeal Circulation: Perfusion System Card. Surg. Adult, January 1, 2008; 3(2008): 350 - 370. [Full Text]

				J. P. Greelish, R. M. Ahmad, J. M. Balaguer, M. R. Petracek, and J. G. Byrne Reoperative Valve Surgery Card. Surg. Adult, January 1, 2008; 3(2008): 1159 - 1174. [Full Text]

				H. Gulbins, A. Pritisanac, and J. Ennker Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation? Ann. Thorac. Surg., March 1, 2007; 83(3): 1219 - 1224. [Abstract] [Full Text] [PDF]

				M L Field, B Al-Alao, N Mediratta, and A Sosnowski Open and closed chest extrathoracic cannulation for cardiopulmonary bypass and extracorporeal life support: methods, indications, and outcomes. Postgrad. Med. J., May 1, 2006; 82(967): 323 - 331. [Abstract] [Full Text] [PDF]

				J. T. Strauch, D. Spielvogel, A. Lauten, S. L. Lansman, K. McMurtry, C. A. Bodian, and R. B. Griepp Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement Ann. Thorac. Surg., July 1, 2004; 78(1): 103 - 108. [Abstract] [Full Text] [PDF]

				M. Pasic, J. Schubel, M. Bauer, C. Yankah, H. Kuppe, Y.-G. Weng, and R. Hetzer Cannulation of the right axillary artery for surgery of acute type A aortic dissection Eur. J. Cardiothorac. Surg., August 1, 2003; 24(2): 231 - 236. [Abstract] [Full Text] [PDF]

				N. Noiseux, P. Couture, P. Sheridan, and R. Cartier Aortic cannulation for type A dissection: guidance by transesophageal echocardiography Interactive CardioVascular and Thoracic Surgery, June 1, 2003; 2(2): 178 - 180. [Abstract] [Full Text] [PDF]

				K. Watanabe, I. Fukuda, M. Osaka, and T. Imazuru Axillary artery and transapical aortic cannulation as an alternative to femoral artery cannulation Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 842 - 843. [Abstract] [Full Text] [PDF]

				E. A. Hessel II and L. H. Edmunds Jr. Extracorporeal Circulation: Perfusion Systems Card. Surg. Adult, January 1, 2003; 2(2003): 317 - 338. [Full Text]

				J. G. Byrne, B. J. Phillips, and L. H. Cohn Reoperative Valve Surgery Card. Surg. Adult, January 1, 2003; 2(2003): 1047 - 1056. [Full Text]

				T. Schachner, K. Vertacnik, G. Laufer, and J. Bonatti Axillary artery cannulation in surgery of the ascending aorta and the aortic arch Eur. J. Cardiothorac. Surg., September 1, 2002; 22(3): 445 - 447. [Abstract] [Full Text] [PDF]

				S. Yavuz, M. T. Goncu, and T. Turk Axillary artery cannulation for arterial inflow in patients with acute dissection of the ascending aorta Eur. J. Cardiothorac. Surg., August 1, 2002; 22(2): 313 - 315. [Abstract] [Full Text] [PDF]

				O. Tasdemir, A. Saritas, S. Kucuker, M. A. Ozatik, and E. Sener Aortic arch repair with right brachial artery perfusion Ann. Thorac. Surg., June 1, 2002; 73(6): 1837 - 1842. [Abstract] [Full Text] [PDF]

				A. Mazzola, R. Gregorini, C. Villani, and M. Di Eusanio Antegrade cerebral perfusion by axillary artery and left carotid artery inflow at moderate hypothermia Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 930 - 931. [Abstract] [Full Text] [PDF]

				E. Neri, M. Massetti, L. Barabesi, G. Pula, R. Tassi, T. Toscano, E. Tucci, A. Benvenuti, G. Capannini, F. Miraldi, et al. Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: Preliminary experience in 26 patients J. Thorac. Cardiovasc. Surg., May 1, 2002; 123(5): 901 - 910. [Abstract] [Full Text] [PDF]

				J. G. Byrne, L. Aklog, D. H. Adams, L. H. Cohn, and S. F. Aranki Reoperative CABG using left thoracotomy: a tailored strategy Ann. Thorac. Surg., January 1, 2001; 71(1): 196 - 200. [Abstract] [Full Text] [PDF]

				J. G. Byrne, A. N. Karavas, D. H. Adams, L. Aklog, S. F. Aranki, G. S. Couper, R. J. Rizzo, and L. H. Cohn Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery Eur. J. Cardiothorac. Surg., September 1, 2000; 18(3): 282 - 286. [Abstract] [Full Text] [PDF]

				K. Imanaka, S. Kyo, H. Tanabe, H. Ohuchi, H. Asano, and Y. Yokote Fatal intraoperative dissection of the innominate artery due to perfusion through the right axillary artery J. Thorac. Cardiovasc. Surg., August 1, 2000; 120(2): 405 - 406. [Full Text] [PDF]

				T. Katoh, H. Gohra, K. Hamano, H. Takenaka, N. Zempo, and K. Esato Right axillary cannulation in the left thoracotomy for thoracic aortic aneurysm Ann. Thorac. Surg., July 1, 2000; 70(1): 311 - 313. [Abstract] [Full Text] [PDF]

				J. D. Whitlark, S. M. Goldman, and F. P. Sutter Axillary artery cannulation in acute ascending aortic dissections Ann. Thorac. Surg., April 1, 2000; 69(4): 1127 - 1128. [Abstract] [Full Text] [PDF]

				J. G. Byrne, S. F. Aranki, G. S. Couper, D. H. Adams, E. N. Allred, and L. H. Cohn REOPERATIVE AORTIC VALVE REPLACEMENT: PARTIAL UPPER HEMISTERNOTOMY VERSUS CONVENTIONAL FULL STERNOTOMY J. Thorac. Cardiovasc. Surg., December 1, 1999; 118(6): 991 - 997. [Abstract] [Full Text] [PDF]

				J. G. Byrne, S. F. Aranki, D. H. Adams, R. J. Rizzo, G. S. Couper, and L. H. Cohn Mitral valve surgery after previous CABG with functioning IMA grafts Ann. Thorac. Surg., December 1, 1999; 68(6): 2243 - 2247. [Abstract] [Full Text] [PDF]

				D. Jegger, H. T. Tevaearai, J. Horisberger, X. M. Mueller, Y. Boone, N. Pierrel, I. Seigneul, and L. K. von Segesser Augmented venous return for minimally invasive open heart surgery with selective caval cannulation Eur. J. Cardiothorac. Surg., September 1, 1999; 16(3): 312 - 316. [Abstract] [Full Text] [PDF]

				E. Neri, M. Massetti, G. Capannini, E. Carone, E. Tucci, F. Diciolla, E. Prifti, and C. Sassi AXILLARY ARTERY CANNULATION IN TYPE A AORTIC DISSECTION OPERATIONS J. Thorac. Cardiovasc. Surg., August 1, 1999; 118(2): 324 - 329. [Abstract] [Full Text] [PDF]

				S. Westaby, T. Katsumata, and G. Vaccari Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome Eur. J. Cardiothorac. Surg., February 1, 1999; 15(2): 180 - 185. [Abstract] [Full Text] [PDF]

				O Merin, S Silberman, R Brauner, Y Munk, N Shapira, G Falkowski, I Dzigivker, and D Bitran Femoro-femoral bypass for repeat open-heart surgery Perfusion, December 1, 1998; 13(6): 455 - 459. [Abstract] [PDF]

				D. A. Cooley Minimally invasive valve surgery versus the conventional approach Ann. Thorac. Surg., September 1, 1998; 66(3): 1101 - 1105. [Abstract] [Full Text] [PDF]

				J. D. Whitlark and F. P. Sutter Intrathoracic subclavian artery cannulation as an alternative to femoral or axillary artery cannulation Ann. Thorac. Surg., July 1, 1998; 66(1): 303 - 303. [Full Text] [PDF]

				J. G. Byrne, S. F. Aranki, and L. H. Cohn Aortic Valve Operations Under Deep Hypothermic Circulatory Arrest for the Porcelain Aorta: "No-Touch" Technique Ann. Thorac. Surg., May 1, 1998; 65(5): 1313 - 1315. [Abstract] [Full Text] [PDF]

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): Sary F. Aranki Gregory S. Couper David H. Adams Robert J. Rizzo John J. Collins, Jr Lawrence H. Cohn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bichell, DavidP. Articles by Cohn, L. H. Search for Related Content PubMed PubMed Citation Articles by Bichell, DavidP. Articles by Cohn, L. H.