Ann Thorac Surg 2000;69:1129
© 2000 The Society of Thoracic Surgeons
ORIGINAL ARTICLES: CARDIOVASCULAR
Invited commentary
Lars G. Svensson, MD, PhDa,
Edward Nadolny, CCPa
a Department of Thoracic and Cardiovascular Surgery, Lahey Clinic, 41 Mall Rd, Burlington, MA, USA 01805
e-mail: lars.g.svensson{at}lahey.org
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Introduction
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 Introduction
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The subclavian/axillary arteries have come to be regarded as useful cannulation sites. Although first used by DeBakey, Cooley, and Crawford for aortic arch operation, Sabik and colleagues popularized the technique for complex cardiac operations. Bichell and colleagues advocated this method for cardiac reoperations when associated with peripheral vascular disease, and Baribeau and colleagues recommended the approach for ascending and arch atherosclerosis. In a 1998 commentary on the excellent autopsy study by Van Arsdell and colleagues, based on our experience with 38 acute dissection repairs, we advised that the subclavian arteries should be cannulated for acute dissection repairs to reduce the risk of malperfusion that may occur with femoral artery cannulation. Subsequently, Neri and colleagues reported on 22 acute dissection repairs using axillary artery cannulation with excellent results. In this report by Whitlark and colleagues, they discuss their experience with axillary cannulation in 13 patients with acute aortic dissection, 8 by direct cannulation, and 5 by suturing a side graft to the artery for acute dissection operations. They also reported no complications with this technique.
The technique is indeed a useful one for acute dissections and complex repairs of the aortic arch. In particular, for acute dissections, we have found the approach to be of importance, because the risk of ischemia is reduced because of a flutter valve effect in the descending or thoracoabdominal aorta during retrograde perfusion through the femoral artery. There are, however, some caveats to consider. We have found that dissection, including acute dissection, may occasionally involve both the subclavian artery and the axillary artery and thus, malperfusion may potentially occur. In addition, if the subclavian artery is cannulated directly, and the catheter is advanced more than 2 cm, it may abut onto the common carotid artery and hence, lead to inadequate flow and even brain ischemia. For small subclavian arteries we recommend that a side graft is used, because flow may otherwise be inadequate, particularly in large, overweight male patients. We have also found the right subclavian artery to be useful for performing complex hypothermic aortic arch repairs whereby we perfuse the brain antegrade through the subclavian and the left common carotid artery and occlude the innominate artery. Retrograde cardioplegia-type inflatable balloon catheters are used for this. Furthermore, we have also used the right subclavian artery in some 12 renal carcinoma patients for arterial perfusion, while doing minimal access parasternal incisions for removal of right atrial tumors. Apart from its use for acute dissections involving the ascending aorta, we use the approach for complex acute dissection repairs involving the descending or thoracoabdominal aorta, including ruptures and reoperations. In this situation, the right subclavian artery is perfused by attaching a side graft to the artery with venous drainage through the left femoral vein using a long, right atrial cannula. Moreover, antegrade brain perfusion can be carried out by occluding the innominate artery and, if necessary, also perfusing the left common carotid artery. The left subclavian artery can also be used in the chest, although, if an aortic arch repair is being contemplated, the catheters in the greater vessels can interfere with exposure. As reported by the authors, and also by others, the use of axillary or subclavian arteries is safe, with a minimal risk of injury to the nerves or problems with repairing the vessel. The vessel, however, is fragile where it lies on the first rib and, therefore, we usually repair it with a 6-0 Prolene suture (Ethicon Inc, Somerville, NJ). If a side graft has been used, we recommend that a stronger suture, such as a 4-0 Prolene suture, be used for oversewing the stump. Thinner sutures may chafe through. In addition, we ligate the stump with a heavy silk suture to reduce the risk of leakage. We prefer to cannulate the subclavian artery proximal to the outer edge of the first rib, rather than the axillary artery per se, because by definition the axillary artery extends distal to the outer edge of the first rib. We, thus, strongly endorse the increasing use of the axillary or subclavian artery for complex cardioaortic operations.
Related Article
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Axillary artery cannulation in acute ascending aortic dissections
- Joseph D. Whitlark, Scott M. Goldman, and Francis P. Sutter
Ann. Thorac. Surg. 2000 69: 1127-1128.
[Abstract]
[Full Text]
[PDF]
