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Ann Thorac Surg 1999;68:1529-1531
© 1999 The Society of Thoracic Surgeons
a Departments of Surgery and Anesthesia, Duke University Medical Center, Durham, North Carolina, USA
Address reprint requests to Dr Glower, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710
e-mail: glowe001{at}mc.duke.edu
Presented at Evolving Techniques and Technologies in Minimally Invasive Cardiac Surgery, San Antonio, TX, Jan 22–23, 1999.
Abstract
Background. Differences in outcome after direct aortic cannulation (AORT) in the chest versus standard femoral arterial cannulation (FEM) have not been defined for minimally invasive cardiac operations utilizing the port-access approach.
Methods. A retrospective study was performed of 165 patients undergoing port-access cardiac mitral valve operation (n = 126) or coronary artery bypass grafting (n = 39). In 113 patients, FEM was used, while in 52 patients, AORT was accomplished through a port in the first intercostal space.
Results. AORT eliminated endoaortic balloon clamp migration (0/36 [0%] vs 17/95 [18%]), and groin wound or femoral arterial complications (0/52 [0%] vs 11/113 [10%]) without changing procedure times (363 ± 55 vs 355 ± 70 minutes). Complications attributable to AORT were injury to the right internal mammary artery and aortic cannulation site bleeding in 1 patient each.
Conclusions. Direct aortic cannulation is technically easy, allows use of an endoaortic clamp, and avoids aorto-iliac arterial disease, the groin incision, and possible femoral arterial injury associated with femoral arterial cannulation. Direct arterial cannulation should expand the pool of patients eligible for port-access operation, and may become the standard for port-access procedures.
Because of limited intrathoracic exposure and lack of specially designed cannulas, catheters, and instrumentation, the initial port-access experience utilized femoral arterial cannulation as opposed to the direct central aortic cannulation [1]. Yet, femoral arterial cannulation is associated with an incidence of groin wound infection, wound seroma, arterial injury requiring reconstruction, aortic dissection, atheroembolism, and limb ischemia [2, 3]. These potential complications along with the incidence of aorto-iliac disease precluding femoral arterial cannulation prompted surgeons to move from femoral arterial to central aortic cannulation over 25 years ago [3].
Recently, techniques and catheters have become available for direct aortic cannulation in minimally invasive cardiac operations using the port-access approach [4]. These new catheters allow both arterial perfusion and insertion of an EndoClamp aortic catheter via the thoracic aorta. To date, data are not available to compare the results of direct cannulation of the aorta with femoral arterial cannulation in minimally invasive cardiac operations. A retrospective study was therefore performed to compare outcome from direct aortic cannulation versus femoral cannulation in minimally invasive cardiac operations using the port-access approach.
Material and methods
The standard 6-cm right or 8- to 12-cm left anterolateral thoracotomy was performed for port-access coronary or mitral operation [5, 6]. The bed of the right 4th rib was opened for mitral procedures. For coronary operations, the left 4th costal cartilage was detached from the sternum and the left 3rd or 4th intercostal space is entered. A reusable chest retractor (Heartport, Inc, Redwood City, CA) was placed in the incision with upward lift on the 2nd and 3rd ribs. The pericardium was opened to the base of the innominate artery, allowing ready access to the ascending aorta.
In femoral arterial patients, a 3- to 4-cm transverse incision was made in the right groin, and the right femoral artery and vein were exposed. The femoral vein was cannulated through two concentric pursestrings of 5-0 polypropylene suture to avoid occlusion of venous return from the right leg. The right femoral artery was cannulated through a transverse arteriotomy. In 56 of 113 (50%) femoral patients, both the proximal and distal femoral artery were perfused to avoid right limb ischemia [2], and in the remaining 57 of 113 (50%) femoral patients, the distal femoral artery was occluded.
In aortic cannulation patients, the right femoral vein was cannulated percutaneously using a 28F venous catheter (Model EDV-28; Heartport, Inc), the tip of which was placed in the right atrium to allow simultaneous right heart emptying and venous drainage of the right leg [4]. Aortic cannulation was initiated by placing a standard 11.5-mm port through the right (mitral patients) or left (coronary patients) first intercostal space. The port pointed directly at the desired cannulation site at the base of the innominate artery [4]. Two standard concentric pursestrings of pledgeted 2-0 polyester were placed at the cannulation site, and the purse-strings were passed through plastic tourniquets and out through either the incision or the 11.5-mm port.
In 36 of 52 (69%) aortic patients, a new aortic cannula and introducer (Direct Flow arterial kit; Heartport, Inc) was used to allow placement of an EndoClamp aortic catheter (EC-65; Heartport, Inc) for aortic occlusion, while in remaining patients, a standard aortic cannula was used either without aortic clamping or with an external aortic clamp. The Direct Flow aortic cannula introducer had a retractable blade to allow easy passage of the cannula through the 11.5-mm port into the pursestring and the aorta [4]. After connecting the aortic cannula to the arterial line, the EC balloon was passed through the aortic cannula, placing the balloon just distal to the tip of the aortic cannula using transesophageal echocardiography or fluoroscopy.
Cardiopulmonary bypass was initiated in standard port-access fashion [1]. To obtain cardiac arrest, the EC was inflated using transesophageal echocardiography or fluoroscopic guidance, gently pulling the EC balloon to the tip of the aortic cannula, thus obtaining a highly stable EC balloon position. After completion of the cardiac operation, cardiopulmonary bypass was stopped, the EC was withdrawn, the aortic cannula was removed, and the aortic purse-strings were secured with direct manual tying through the thoracotomy. The venous cannula was withdrawn, holding pressure on the groin for 10 to 15 min after the protamine is given. The venous puncture site was closed with 2-0 absorbable suture in the deep subcutaneous tissue and two 3-0 absorbable interrupted subcuticular sutures [4].
Results
In 165 patients, cardiac mitral valve operation (n = 126) or coronary artery bypass grafting (n = 39) was performed using port-access. In 113 patients, femoral cannulation was used, while direct aortic cannulation was used in all patients for whom aortic cannulation was available (52 unselected patients). Patient characteristics and procedures performed were well matched between aortic and femoral groups (Table 1). Specific indications for aortic cannulation were small femoral artery less than 21 F (n = 9), aorto-iliac disease (n = 16), or obesity (n = 5). Of the 52 patients in whom aortic cannulation was used, 7 of 10 (70%) coronary patients and 23 of 42 (55%) mitral patients had contraindications to femoral artery cannulation, suggesting that aortic cannulation expanded the pool of patients eligible for port-access by 7 over 3 (233%) in coronary patients and 23 over 19 (121%) in mitral patients. Aortic cannulation eliminated EndoClamp migration (0/36 [0%] vs 17/95 [18%], p < 0.01), groin wound, or femoral arterial complications (0/52 [0%] vs 11/113 [10%], p < 0.01) (Table 2) without changing cardiopulmonary bypass times (182 ± 49 vs 198 ± 49 min) or procedure times (352 ± 95 vs 356 ± 71 minutes). The only complications directly attributable to direct aortic cannulation were injury to the right internal mammary artery and aortic cannulation site bleeding in 1 patient each.
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These results demonstrate that, relative to femoral arterial cannulation, direct aortic cannulation for port-access is safe, allows easy use of endoaortic occlusion, and eliminates the limitations and potential morbidity of femoral arterial cannulation. The potential does exist for injury to the aortic back wall of the aorta during insertion of the cannulas used, but this complication was not observed in the current series. In the future, direct cannulation of the right atrium through the chest wall should be feasible and eliminate all access to the groin. Nonetheless, percutaneous femoral vein cannulation has had little if any morbidity.
Relative indications for direct aortic cannulation include the presence of aorto-iliac arterial disease, femoral arterial size less than 21F and obesity. The relative contraindications for direct aortic cannulation are few and include significant atherosclerosis of the ascending aorta and severe deformity of the superior chest wall. Aortic root diameter greater than 3.5 cm is a relative contraindication to use of the EndoClamp catheter, but does not contraindicate direct aortic cannulation. Given the frequency of relative contraindications to femoral arterial cannulation in an aging cardiac surgical population, direct aortic cannulation should expand the pool of patients eligible for port-access operation. In this series of patients, direct aortic cannulation may expand the pool of patients eligible for port-access by 7 over 3 (233%) in coronary patients and 23 over 19 (121%) in mitral patients. Decreased patient morbidity, ease of use, and applicability to a broader patient pool all favor direct aortic cannulation as the standard technique for port-access.
Footnotes
Dr Glower has received an honorarium from, and Dr Stafford-Smith has received a research grant from Heartport, Inc (Redwood City, CA).
References
This article has been cited by other articles:
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  Y. Suzuki, F. D. Pagani, and S. F. Bolling Left Thoracotomy for Multiple-Time Redo Mitral Valve Surgery Using On-Pump Beating Heart Technique Ann. Thorac. Surg., August 1, 2008; 86(2): 466 - 471. [Abstract] [Full Text] [PDF]
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 F. Farhat, M. Vergnat, P. Blanc, P. Chiari, and O. Jegaden Which place for Port AccessTM surgery in coronary artery bypass grafting? A mid-term follow up study Interactive CardioVascular and Thoracic Surgery, February 1, 2006; 5(1): 71 - 74. [Abstract] [Full Text] [PDF]
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 B. E. Muhs, A. C. Galloway, M. Lombino, M. Silberstein, E. A. Grossi, S. B. Colvin, P. Lamparello, G. Jacobowitz, M. A. Adelman, C. Rockman, et al. Arterial Injuries from Femoral Artery Cannulation with Port Access Cardiac Surgery Vascular and Endovascular Surgery, March 1, 2005; 39(2): 153 - 158. [Abstract] [PDF]
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 P. C. Saunders, E. A. Grossi, R. Sharony, C. F. Schwartz, G. H. Ribakove, A. T. Culliford, J. Delianides, F. G. Baumann, A. C. Galloway, and S. B. Colvin Minimally invasive technology for mitral valve surgery via left thoracotomy: Experience with forty cases J. Thorac. Cardiovasc. Surg., April 1, 2004; 127(4): 1026 - 1032. [Abstract] [Full Text] [PDF]
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 T J Spyt and A C De Souza Minimally invasive therapy and robotics: Treatments in ischaemic heart disease Br. Med. Bull., October 1, 2001; 59(1): 261 - 268. [Full Text] [PDF]
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D. D. Glower, J. Komtebedde, F. M. Clements, N. P. Debruijn, M. Stafford-Smith, and M. F. Newman Direct aortic cannulation for port-access mitral or coronary artery bypass grafting Ann. Thorac. Surg., November 1, 1999; 68(5): 1878 - 1880. [Abstract] [Full Text] [PDF]
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