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Ann Thorac Surg 2000;69:317
© 2000 The Society of Thoracic Surgeons

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Correspondence

Axillary cannulation

^a Catholic Medical Center, 100 McGregor St, Manchester, NH 031202, USA

To the Editor

We read with interest the recent article by Leyh and colleagues regarding axillary cannulation for calcification of the aorta [1]. They describe direct axillary cannulation and fibrillatory arrest for construction of the distal anastomosis with innominate inflow or aortic proximal vein reconstruction in the so-called clean area by palpation under circulatory arrest, thus avoiding cross-clamping the calcified aorta. The technique was used in 23 of 1,861 patients for a 2% incidence of significant calcified aorta by palpation. Although the term porcelain aorta was used, we restrict the term for rare occurrence of complete rock solid calcification of the proximal aorta. All operations involved coronary bypass and there were no strokes. One patient had brachial plexus injury, for an incidence of 4.3%. No epiaortic ultrasound was used. There was no mention of carotid disease in the patients.

First we would like to emphasize, as done by Leyh and colleagues, that epiaortic ultrasound is more sensitive than any other technique for detection of the "bad" aorta, exception made of the severely calcified aorta, but these still constitute the minority of the 8% severely diseased aortas encountered in a general cardiac surgical population [2]. Most of these are normal to palpation and contain mobile atherosclerotic debris.

As for the axillary technique of cannulation, we favor a more medial approach with avoidance of the brachial plexus roots as it reaches the artery more laterally. Graft interposition avoids any contact between the friable artery and the inflow cannula. The graft is used for patch closure at the end of the operation and again avoids potential catastrophic tear of the artery by a purse string suture or rigid cannula. We have had no local complications to date in more than 80 patients. Sabik reported a 5.7% incidence of neurovascular injury of 35 patients in the Cleveland Clinic experience using direct cannulation (including one axillary artery thrombosis), similar to Dr Leyh and colleagues [3].

Also axillary cannulation is ideal for antegrade brain perfusion by simply clamping the origin of the innominate after ruling out significant atherosclerotic involvement by ultrasound [3], and has been used in cases of circulatory arrest including proximal vein graft anastomosis as described by Dr Leyh.

Lastly, mention should be made of beating heart operation as one strategy to avoid manipulation of these aorta. Although it clearly reduces the risk of stroke, one may wonder whether a more aggressive approach is warranted in younger patients in view of the high incidence of stroke on follow-up in these patients, particularly in cases of mobile atherosclerotic or thrombotic debris [4, 5].

We congratulate Leyh and colleagues for their excellent results and agree with their choice for extraaortic cannulation site.

References

1. Leyh R., Bartels C., Notzold A., Sievers H.H. Management of porcelain aorta during coronary artery bypass grafting. Ann Thorac Surg 1999;67:986-988.[Abstract/Free Full Text]
2. Baribeau YR, Westbrook BW. Intra-operative epicardial echocardiography. In: Izzat, Sanderson JE, eds. Echocardiography in adult cardiac surgery. ISIS Medical Media Ltd, 1999:.
3. Sabik J.F., Lytle B.W., McCarthy P.M., Gosgrove D.M. Axillary artery. J Thorac Cardiovasc Surg 1995;109:885.[Abstract]
4. Amarenco P., French Study of Aortic Plaques in Stroke Group. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996;334:1216-1221.[Medline]
5. Baribeau Y.B., Westbrook B.M., Charlesworth D.C., Maloney C.T. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg 1998;66:33-37.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Yvon R. Baribeau Benjamin M. Westbrook Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Baribeau, Y. R. Articles by Westbrook, B. M. Search for Related Content PubMed PubMed Citation Articles by Baribeau, Y. R. Articles by Westbrook, B. M.