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Ann Thorac Surg 1999;68:1517-1519
© 1999 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Riverside Methodist Hospitals, Columbus, Ohio, USA
Address reprint requests to Dr Watson, Cardiothoracic and Vascular Surgical Associates Inc, 3555 Olentangy River Rd, Suite 2070, Columbus, OH 43214
Presented at Evolving Techniques and Technologies in Minimally Invasive Cardiac Surgery, San Antonio, TX, Jan 22–23, 1999.
Abstract
Background. Minimally invasive port-access coronary artery bypass surgery has many potential advantages over routine median sternotomy coronary revascularization in patients with serious co-morbid conditions. The common femoral artery and vein have been the standard peripheral cannulation and balloon deployment sites. However, these sites present some risk, especially from proximal arteriosclerotic or aneurysmal disease.
Methods. We utilized Heartport endovenous and endoaortic cannulas (Heartport Inc, Redwood City, CA) for axilloaxillary or femoral-descending aortic cardiopulmonary bypass in 9 patients in an attempt to avoid potential cerebral and systemic embolization. All patients were successfully cannulated and the endoaortic clamp was deployed to perform a total of eleven grafts (five right coronary arteries and six circumflex coronary arteries). The patients ranged from 66 to 80 years of age. Five patients had abdominal aortic aneurysmal disease and 4 had severe peripheral vascular disease.
Results. All patients achieved full cardiopulmonary bypass with flows in excess of 3 L/min. without difficulty. There were no complications referable to the arm and its neurovascular structures. All axillary arteriotomies were closed primarily, without the need for thrombectomy or reconstruction. There were no neurological complications and 30-day survival was 100%. Three patients underwent successful abdominal aortic aneurysm resection prior to discharge.
Conclusions. Axilloaxillary and femoral-descending aortic cannulation utilizing standard Heartport cannulas (Heartport, Inc) offer alternative sites for cardiopulmonary bypass in patients with severe peripheral vascular disease.
Performing minimally invasive cardiac operations using cardiopulmonary bypass (CPB) and cardioplegic arrest has become a well accepted technique with Heartport instrumentation (Heartport, Inc). This system utilizes femoral arterial and venous access for CPB and a transfemoral endoaortic occlusion catheter. However, utilization of these sites presents technical and embolic problems in patients with aortoiliac aneurysmal disease or arteriosclerotic arterial obstruction. Axillary artery cannulation has been described for CPB arterial inflow in patients with prohibitive peripheral vascular disease. We report our experience with axillary artery and descending aortic cannulation, with standard Heartport endoarterial return cannulas (Heartport, Inc), for CPB inflow and endoaortic clamp deployment. This approach was utilized to revascularize complex, isolated lesions in the right coronary artery and circumflex distributions, in patients with contraindication to conventional femoral artery cannulation.
Material and methods
We utilized Heartport endovenous and endoaortic cannulas (Heartport, Inc) for axilloaxillary (2 patients), femo-roaxillary (3 patients), and femorodescending CPB (4 patients) in a total of 9 patients in an attempt to avoid potential cerebral and systemic embolization. Five patients were excluded from femoral arterial cannulation due to aortic aneurysmal disease, while 4 were excluded for severe peripheral vascular disease. The patients ranged from 66 to 80 years of age. Their aortoiliac disease was determined by imaging at the time of coronary angiography (6) or previous peripheral angiograms (3). A total of eleven grafts were performed in this population, consisting of five right internal mammary (pedicle) to right coronary artery and six circumflex revascularizations (saphenous vein graft as conduit and descending aorta as proximal in all instances).
Patients were selected for this approach when thallium imaging was positive during preoperative cardiac work-up prior to aortic revascularization. When cardiac catheterization showed isolated right coronary or complex circumflex coronary artery lesions not amenable to angioplasty, minimally invasive port-access coronary revascularization was performed prior to aortic surgery.
Dissection of the axillary artery in the mid-clavicular line has been described on numerous occasions. After mobilization from its loose investing fascia, and systemic heparinization, proximal and distal control are attained utilizing elastic vascular tapes. A transverse arteriotomy is performed and a 21F or 23F Heartport endoarterial cannula is inserted via Seldinger technique. A tourniquet and skin sutures are used to stabilize the cannula after connecting it to the CPB pump tubing circuit (Fig 1). Right internal mammary artery harvest and femoral vein exposure (when required) is performed concomitantly during the aforementioned dissection.
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There were no complications related to the technique. All axillary artery and descending aortic cannulation attempts were successful: CPB flow in excess of 3 L per minute was achieved in all cases, along with proper function of the endoaortic clamp. All axillary arteriotomies were closed primarily without the need for thrombectomy or reconstruction. There were no complications referable to the arm or its neurovascular structures. There were no neurologic complications and 30-day survival was 100%. Three patients underwent successful abdominal aortic aneurysm repair prior to discharge.
Eight of 9 patients were free of angina at 6-week follow-up. The last patient underwent recatheterization, which exhibited a patent operative graft (Fig 3 ) without evidence of a cardiac cause for the patient’s residual chest pain.
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The common femoral artery is the standard site for peripheral cannulation for cardiopulmonary bypass. However, in the presence of proximal aortic disease, considerable risk of embolism due to retrograde perfusion exists in aneurysmal disease as well as an added risk of low flow/propagated dissection exists in arteriosclerotic occlusive disease. End-organ injury such as renal failure, stroke, and mesenteric ischemia, secondary to dislodgment of intraluminal debris, are known sequelae [1].
The axillary artery is rarely affected by atherosclerotic disease even in the setting of extensive involvement of the aorta, iliac, and innominate artery. In addition, the axillary artery enjoys rich collateralization from its proximal tributaries, allowing total occlusion of the vessel to be performed without the threat of reperfusion injury or upper extremity ischemia [2].
For operations involving revascularization of the heart via a left thoracotomy, the descending aorta provides a convenient site for arterial inflow and with the aid of fluoroscopy, an easy conduit for passage of an endoaortic occlusion balloon. Although the circumflex coronary artery can be revascularized by stabilization platforms if desired [3], cardiopulmonary bypass, cardioplegic arrest, and coronary venting aid the performance of grafts to small, intramyocardial vessels with the added benefit of assured hemodynamic stability [4].
Remote cannulation and minimally invasive coronary revascularization have the added benefit of avoiding midline and groin incisions, as well as sternotomy, in patients who will require a midline abdominal incision (and possible groin incisions) to address their aortoiliac pathologies. This accelerates the physical therapy and ambulation of these patients perioperatively.
In conclusion, the axillary artery and descending aorta are safe and effective alternatives to femoral artery inflow for patients in whom port-access coronary revascularization is to be performed. These options are especially valuable in patients with prohibitive aortic aneurysmal or peripheral occlusive disease in whom retrograde perfusion or wire/endoaortic balloon passage could be difficult or potentially hazardous.
References
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