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Ann Thorac Surg 2000;69:1127-1128
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: CARDIOVASCULAR

Axillary artery cannulation in acute ascending aortic dissections

^a Main Line Cardiothoracic Surgeons, Lankenau Hospital, Jefferson Health System, Wynnewood, Pennsylvania, USA

Address reprint requests to Dr Whitlark, Main Line Cardiothoracic Surgeons, Lankenau Hospital, Medical Science Building, Suite 280, 100 Lancaster Ave, Wynnewood, PA 19096
e-mail: mlcts2220{at}aol.com

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Standard cannulation of the femoral artery in preparation for repair of a dissection involving the ascending aorta carries a high risk of malperfusion. Arterial perfusion through the right axillary artery is more likely to perfuse the true lumen and should be advantageous in acute dissections involving the ascending aorta.

Methods. Thirteen patients underwent repair of acute ascending aortic dissections and were perfused through the right axillary artery. All had deep hypothermic circulatory arrest.

Results. There was one mild intraoperative cerebrovascular accident with complete recovery and one operative death secondary to low cardiac output. There were no intraoperative problems with perfusion through the axillary artery, and there were no postoperative problems or complications involving the axillary artery, axillary vein, or brachial plexus.

Conclusions. Arterial perfusion through the right axillary artery is a safe and effective means of more reliably perfusing the true lumen. In this regard, it may be superior to femoral artery perfusion and could lead to improved outcomes with repair of acute deBakey type I and II aortic dissections.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Acute dissection of the ascending aorta is a surgical emergency associated with significant morbidity and mortality. Historically, arterial cannulation in preparation for repair of a dissection involving the ascending aorta has been performed through the femoral artery [1]. This has been associated with many problems, including lower extremity ischemia, compartment syndrome, neurologic injury, wound complications, propagation of a retrograde dissection, dislodgment and retrograde embolization of luminal debris, and especially end-organ ischemia caused by malperfusion [2, 3]. A recent autopsy study of patients with aortic dissections demonstrated that a large percentage of patients were at risk for malperfusion if the femoral artery were used for perfusion [4]. Perfusing the right axillary artery has been recommended by some authors for acute dissections and may obviate many of these problems [4–7]. We have used axillary artery cannulation in more than 50 patients for many reasons, including atheromatous or calcified ascending aortas and repair of large ascending aortic aneurysms. We present our experience with axillary artery cannulation and perfusion for repair of deBakey type I and II aortic dissections.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Surgical technique
Bilateral radial artery monitoring lines are placed to assess flow to both axillary arteries. The right axillary artery is approached through an incision made below the clavicle in the deltopectoral groove. The pectoralis major muscle is divided in the direction of its fibers. The pectoralis minor is retracted laterally. The axillary vein is mobilized and retracted, and the axillary artery is mobilized. The artery is clamped proximally and distally. The first 8 patients had direct cannulation, and the last 5 patients were cannulated by suturing an 8.0-mm polyethylene terephthalate fiber graft to a longitudinal arteriotomy with 6.0 Prolene (Ethicon, Inc, Somerville, NJ) and then inserting a 22F cannula into the graft. This fits snugly and is secured with a heavy silk tie. The cannula is attached to the arterial return tubing and fixed to the drapes.

The chest is opened by means of a sternotomy and both cavae are cannulated. Cardiopulmonary bypass is begun, and a left ventricular vent is placed through the right superior pulmonary vein. If the heart distends secondary to severe aortic insufficiency, the aorta is cross-clamped. When the core temperature has reached 18°C, and the patient has been cooled for approximately 40 minutes, total circulatory arrest with retrograde cerebroplegia from the bypass circuit and retrograde cardioplegia is begun. The aorta is opened and inspected. If the arch is involved, then replacement of the arch is performed with or without an elephant trunk extension. If the tear is confined to the ascending aorta, a graft is sutured to the distal ascending aorta with felt strip supports. A cross-clamp is applied to the graft, cardiopulmonary bypass is resumed through the axillary artery, and the patient is rewarmed. The proximal aorta and aortic valve is then assessed, and the appropriate procedure is performed.

After weaning from cardiopulmonary bypass, protamine is administered. The axillary graft is simply clamped and cut approximately 5 mm from the anastomosis. The graft is oversewn with 6.0 Prolene (Ethicon, Inc) in two layers.

Patients
Between March 9, 1996, and February 7, 1999, 13 consecutive patients with acute dissections involving the ascending aorta underwent surgical repair with arterial perfusion through the right axillary artery. Ages ranged from 47 to 84 years. There were 8 men and 5 women. One patient had a reoperative sternotomy. All patients had cannulation of the right axillary artery, and all had midline sternotomies. The ascending aorta was replaced in all 13 patients. One patient required reimplantation of the coronary arteries. The aortic valve was spared in all 13 cases, with resuspension of the valve in 6 patients. Coronary artery bypass grafting was performed in 2 patients. An existing saphenous vein graft was reimplanted to the aortic graft in 1 patient. The arch was replaced in 2 patients with one elephant trunk extension. Peak flows through the axillary artery ranged from 3.5 to 5.5 L/min, and arterial flows were satisfactory in all cases.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Preoperatively, 4 patients presented with profound neurologic symptoms, with 3 patients presenting with paraplegia and 2 patients presenting with right hemiplegia (1 patient had hemiplegia and paraplegia). Both patients with right hemiplegia recovered in the immediate postoperative period. Of the 3 with paraplegia, 1 recovered fully in the immediate postoperative period. One recovered fully in the left lower extremity, but was paralyzed in the right lower extremity, presumably from an ischemic sacral plexopathy. The remaining patient had persistent paraplegia postoperatively. One patient had a mild right hemispheric cerebral vascular accident intraoperatively and recovered fully. There was one operative death from low cardiac output in an 84-year-old woman. There were no late deaths. Of the 12 patients surviving surgery, 2 experienced renal failure requiring temporary dialysis and 1 had renal insufficiency that did not require dialysis. All 3 patients had return of renal function with normalization of serum creatinine. Stay in the intensive care unit ranged from 1 to 40 days. Hospital stay ranged from 5 to 70 days. There were no neurologic or vascular complications involving the right upper extremity.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
There are some advantages to this technique compared with more commonly described cannulation methods. With femoral cannulation, a common practice is to cannulate the aortic graft after the distal anastomosis is performed to assure that the true lumen is being perfused. It is unusual for the right axillary artery to be involved with an intimal flap from an acute dissection, and this has not been noted in our experience [1]. Perfusion of the true lumen is of paramount importance in the repair of acute dissections, and not only does this method reliably perfuse the true lumen from the start of the operation, but it also eliminates the extra step of having to cannulate the aortic graft. In addition, by using a graft sutured directly to the axillary artery, perfusion to the right upper extremity is maintained. The importance of true lumen perfusion in these often critically ill patients cannot be stressed enough. Malperfusion is one of the major factors contributing to the morbidity and mortality associated with acute aortic dissections. The cannulation of the right axillary artery is simple and appears to more reliably perfuse the true lumen as soon as cardiopulmonary bypass is begun.

Besides eliminating the problems with the lower extremities associated with femoral cannulation intraoperatively and local problems postoperatively, the ease with which decannulation is performed is notable. The clamping, cutting, and oversewing of the graft to the axillary artery is simple and fast and can be performed after protamine is infused. It is also safe. In more than 50 patients cannulated through the axillary artery in our experience, we have seen no local infections, drainage, brachial plexus injuries, or vascular compromise.

Despite improvements in cerebral protection, graft material, and myocardial protection in recent years, the morbidity and mortality of surgical repair of acute deBakey type I and II dissections remains relatively high. Malperfusion preoperatively and intraoperatively contributes to the morbidity and mortality associated with these operations. Arterial perfusion through the right axillary artery for repair of acute dissections involving the ascending aorta is safe and simple, has fewer complications, and, by perfusing the true lumen from the beginning of cardiopulmonary bypass, may lead to improved outcomes.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Borst H.G. Surgical treatment of aortic dissection. New York: Churchill Livingston, 1996:31-33.
2. Eugene J., Aronow W.S., Stemmer E.A. Retrograde aortic dissection during cardiopulmonary bypass. Clin Cardiol 1981;4:356-359.[Medline]
3. Tanemoto K., Kuinose M., Kanaoka Y. Complications of femoral artery cannulation in aortic arch related operations. Nippon Kyobu Geka Gakkai Zasshi 1994;43:306-310.
4. Van Arsdell G.S., David T.E., Butany J. Autopsies in acute type A aortic dissection. Circulation 1998;98(Suppl):II299-II304.
5. Bichell D.P., Balaguer J.M., Aranki S.F., et al. Axilloaxillary cardiopulmonary bypass. Ann Thorac Surg 1997;64:702-705.[Abstract/Free Full Text]
6. Baribeau Y.R., 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]
7. Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D.M. Axillary artery. J Thorac Cardiovasc Surg 1995;109:885-891.[Abstract]

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This Article Abstract Full Text (PDF) 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): Scott M. Goldman Francis P. Sutter Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Whitlark, J. D. Articles by Sutter, F. P. Search for Related Content PubMed PubMed Citation Articles by Whitlark, J. D. Articles by Sutter, F. P. Related Collections Related Article