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Ann Thorac Surg 2004;77:1315-1320
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Cannulation of the axillary artery with a side graft reduces morbidity

Joseph F. Sabik, MDa*, Hassan Nemeh, MDa, Bruce W. Lytle, MDa, Eugene H. Blackstone, MDa,b, A. Marc Gillinov, MDa, Jeevanantham Rajeswaran, MSb, Delos M. Cosgrove, MDa

a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
b Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication August 15, 2003.

* Address reprint requests to Dr Sabik, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195, USA
e-mail: sabikj{at}ccf.org


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
BACKGROUND: The axillary artery is our preferred arterial cannulation site when the ascending aorta cannot be cannulated. Previously, we cannulated the artery directly; now we use a side graft. The purposes of this study were to (1) investigate cannulation-related morbidity and (2) determine whether use of a side graft reduces it.

METHODS: From January 1993 to January 2001, 392 patients underwent 399 axillary artery cannulations. Indications included calcified ascending aorta (129, 32%), ascending aortic aneurysm (115, 29%), type I aortic dissection (85, 21%), cardiac reoperation (70, 18%), and calcified femoral artery (26, 6%). The axillary artery was cannulated directly in 212 (53%) and with a side graft in 187 (47%). Comparisons of cannulation-related morbidity between the direct cannulation and side graft groups were made overall and after both adjusting and matching for propensity score.

RESULTS: Cannulation-related morbidity was infrequent, with brachial plexus injury in 7 (1.8%), axillary artery damage in 7 (1.8%), aortic dissection in 3 (0.8%), and arm ischemia in 3 (0.8%). Only 4 of 187 (2.1%) occurred in the side graft group, versus 16 of 212 (7.0%) with direct cannulation (p = 0.03). After propensity adjustment, the odds ratio for reduction of risk of cannulation-related morbidity with use of a side graft was 0.15 (p = 0.002).

CONCLUSIONS: Use of the axillary artery as inflow for cardiopulmonary bypass is associated with low morbidity. However, cannulation with a side graft was associated with less cannulation-related morbidity than direct cannulation. Routine use of a side graft is recommended whenever axillary artery cannulation is indicated.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
The axillary artery has become our preferred site of arterial cannulation for cardiopulmonary bypass when the ascending aorta is unsuitable for cannulation [1]. Early in our experience, the axillary artery was cannulated directly; however, we now cannulate it using a prosthetic side graft. The purposes of this study were (1) to investigate cannulation-related morbidity and (2) to determine whether use of a side graft reduces it.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Patients
From January 1993 to January 2001, 392 patients underwent 399 axillary artery cannulations at The Cleveland Clinic Foundation. Seven required reoperations at a later date and had cannulation of the contralateral axillary artery. Mean age of patients was 67 ± 12 years (range, 18 to 90 years), and 64% were male. Indications (multiple for some patients) for axillary artery cannulation were calcified ascending aorta in 129 (32%), ascending aortic aneurysm in 115 (29%), type I aortic dissection in 85 (21%), cardiac reoperation in 70 (18%), and calcified femoral artery in 26 (6%). It was cannulated directly in 212 operations (53%) and with a side graft in 187 (47%). Early in our experience we cannulated the artery directly; however, we now more commonly cannulate the artery with a side graft (Fig 1). The right axillary artery was used in 377 procedures (95%; laterality was not documented in 2 patients).



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  		Fig 1. Yearly number of axillary artery cannulations performed either directly or with a side graft.

 
Preoperative axillary artery evaluation
To avoid malperfusion, the brachiocephalic arteries should be evaluated preoperatively for occlusive disease. This can be performed either by comparing brachial cuff pressures or, preferably, by ultrasound examination. If important stenosis is identified, the affected axillary artery should not be cannulated.

Technique of axillary artery cannulation
The axillary artery is exposed through a 6- to 8-cm incision below and parallel to the lateral two thirds of the clavicle (Fig 2A). The pectoralis major is divided in the direction of its fibers and the clavipectoral fascia incised, exposing the pectoralis minor, which may be divided or retracted laterally. Using sharp dissection, the artery is dissected from surrounding tissue (Fig 2B). Care is taken not to injure the brachial plexus. Proximal and distal control of the axillary artery is obtained. After administration of heparin the artery is cannulated, either directly through a pursestring suture (Fig 3A) or by means of a 10-mm prosthetic side graft anastomosed to the axillary artery (Fig 3B). By cannulating the artery in its medial portion, the brachial plexus is usually avoided.



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  		Fig 2. (A) Site of infraclavicular incision used for axillary artery exposure. (B) Exposed axillary artery and relationship to axillary vein and brachial plexus.

 


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  		Fig 3. (A) Direct cannulation of axillary artery with right angle arterial cannula (note division of crossing vein). (B) Cannulation of axillary artery with a side graft. Straight arterial cannula inserted into graft.

 
After cardiopulmonary bypass is terminated, the axillary artery is repaired. If direct cannulation is used, the pursestring suture is removed and the axillary artery is repaired primarily or with a saphenous vein patch if primary closure would narrow the artery. If a side graft is used, it is clamped as close to the axillary artery as possible, divided just distal to the clamp, and oversewn. To eliminate the small stump that results from the residual side graft, a large metallic clip is placed at the base of the graft.

Operative procedures
All operations were performed through a median sternotomy. Eighty-four percent of patients had procedures involving the ascending aorta (Table 1). Ascending aortic replacement was performed in 226 (58%), aortic root replacement in 80 (20%), and aortic endarterectomy in 24 (6%). Hypothermic circulatory arrest was performed in 257 patients (64%).


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  		Table 1. Procedures Performed

 
Data collection
Patients were identified from the prospective Cardiovascular Information Registry, from which preoperative, operative, and postoperative variables were retrieved. In addition, medical records were reviewed to confirm and augment these data. The Cleveland Clinic's Institutional Review Board approved use of these data for research.

Statistical methods
Analysis of morbidity
Three methods of comparing hospital morbidity were used. First, hospital outcomes were compared between the direct axillary artery cannulation patients and those cannulated via a prosthetic side graft, with no risk adjustment. Second, they were compared between propensity-matched patients. Third, the odds ratio of morbidity due to axillary artery cannulation was compared by logistic regression after adjustment for propensity score. We used the {chi}2 test for comparisons when the minimum number of patients in a morbidity category was greater than five, and Fisher's exact test otherwise.

Medical records were examined to identify evidence of morbidity related to axillary artery cannulation, including arm ischemia, brachial plexus injury, axillary artery injury, and aortic dissection. In-hospital morbidity was also documented, including cerebral vascular accident, respiratory insufficiency, gastrointestinal bleeding, renal failure, sepsis, reoperation for bleeding, and death.

Propensity matching and adjustment
To reduce the influence of selection on comparison of morbidity, we used propensity matching and adjustment. Using preoperative and intraoperative variables (Table A1) and multivariable logistic regression, we determined the factors associated with receiving direct or side graft axillary artery cannulation (group membership). We examined continuous and ordinal variables using decile analysis, selecting those transformations of scale that best calibrated variables to group membership.


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  		Appendix Table A1. Patient Characteristics and Comparison by Axillary Artery Cannulation Technique

 
Variable selection, with a p value criterion of 0.05 for retention of variables in the model, used bootstrap bagging (bootstrap aggregation) [2, 3]. This was a four-step process. First, a patient was randomly selected from the original data set to begin a new data set. The original data set continued to be sampled until the new data set was 100% the size of the original. Second, risk factors were identified using automated forward stepwise selection. Third, results of the variable selection were stored. These three steps were repeated 1,000 times. Finally, the frequency of occurrence of variables related to group membership was ascertained and indicated the reliability of each variable (aggregation step). All variables with bootstrap reliability of 50% or greater were retained in the guided analysis.

Having established a parsimonious model (Table A2), we added other variables representing groups of patient and coronary disease factors that might be related to unrecorded selection factors (saturated model). The c statistic was 0.7. A propensity score was calculated for each patient by solving the saturated model for the probability of side graft cannulation.


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  		Appendix Table A2. Factors Associated With Use of Side Graft and Direct Cannulation

 
Using only the propensity score, direct cannulation cases were matched to side graft cannulation cases using a greedy matching strategy [4]. For this, matching to 5 decimal points was initially performed, followed by 4, 3, 2, and 1 decimal-point matching. Side graft cannulation cases whose propensity scores deviated more than 0.10 from those of direct cannulation cases were considered unmatched. This yielded 140 side graft axillary artery cannulation cases propensity matched to 140 direct axillary artery cannulation cases. In addition, the odds ratio for comparing morbidity due to axillary artery cannulation and technique of cannulation was adjusted by the propensity score in a two-variable logistic regression model.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Entire group
Mortality and morbidity
Hospital mortality for the entire group was 8%. The most common postoperative complications were respiratory insufficiency and sepsis, occurring in 24% and 9% of patients, respectively (Table 2).


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  		Table 2. Morbidity for Entire Group and by Axillary Artery Cannulation Technique

 
Morbidity due to axillary artery cannulation
Complications related directly to axillary artery cannulation were rare, occurring in 5.0% of patients (Table 2). The most common complications were brachial plexus injury and axillary artery injury, each seen in 7 patients (1.8%). Arm ischemia and aortic dissection each occurred in 3 patients (0.8%).

Unmatched comparison
Mortality and morbidity
Mortality in the direct and side graft cannulation patients was 7.6% and 8.6%, respec-tively (p = 0.7). Systemic morbidity was similar in both groups (Table 2).

Morbidity due to axillary artery cannulation
Complications related directly to axillary artery cannulation were higher in patients with direct cannulation than in those who had a side graft (7.5% versus 2%, p = 0.03; Table 2). Aortic dissection occurred in 3 (1.4%) patients who underwent direct cannulation, but in no patient who had a side graft (p = 0.2). Also, brachial plexus injury was more common in patients undergoing direct cannulation (2.8% versus 0.5%, p = 0.1). Odds ratio for risk reduction by the side graft technique was 0.29 (68% confidence limits, 0.16 to 0.51; p = 0.03).

Propensity-adjusted comparison
Mortality and morbidity
Hospital mortality for the propensity-matched patients undergoing direct axillary artery cannulation and cannulation by means of a prosthetic side graft was 6.4% and 9.3%, respectively (p = 0.4). Systemic morbidity was also similar in the two groups (Table 3).


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  		Table 3. Morbidity for Propensity-Matched Pairs

 
Morbidity due to axillary artery cannulation
Occurrence of cannulation-related complications in the propensity-matched patients was 1% in the side graft group and 8% in the direct cannulation group (p = 0.02; Table 3). Brachial plexus injury (p = 0.06) and axillary artery injury (p = 0.03) occurred more often in the direct cannulation group. Odds ratio for risk reduction after propensity adjustment was 0.15 (68% confidence limits, 0.08 to 0.28; p = 0.002).


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Background
The axillary artery has become our, as well as that of others, preferred site of arterial cannulation for cardiopulmonary bypass when the ascending aorta is unsuitable [1, 5, 6]. We believe axillary artery cannulation has several advantages over femoral artery cannulation. First, patients with important ascending aortic arteriosclerosis usually have severe abdominal aortic arteriosclerosis [7]. Retrograde perfusion, by means of the femoral arteries, through an arteriosclerotic aorta can result in stroke and visceral organ injury from atheroemboli [8]. Axillary artery cannulation eliminates this risk by providing antegrade perfusion. Second, patients with arteriosclerotic ascending aortas often have severe iliofemoral arteriosclerosis, rendering the femoral arteries unsuitable for cannulation. The axillary artery is usually free from arteriosclerotic disease [6]. Third, in type I aortic dissections, the dissection usually does not extend into the axillary arteries, making them a reliable site for arterial cannulation with a low risk of organ malperfusion [9]. Fourth, axillary artery cannulation along with innominate artery occlusion provides a means of antegrade perfusion of the brain during periods of hypothermic circulatory arrest. Contraindications to axillary artery cannulation include arteriosclerotic axillary or subclavian vessels and extension of aortic dissection into the axillary artery.

Two different techniques may be used to cannulate the axillary artery: (1) a straight or angled cannula may be placed directly into the axillary artery, or (2) a side graft may be anastomosed onto the axillary artery and then cannulated with a straight cannula.

Principal findings
Axillary artery cannulation is a safe and reliable method of arterial cannulation for cardiopulmonary bypass. Cannulation-related complications are rare, with the most common being brachial plexus and axillary artery injury. Complications related directly to axillary artery cannulation can be reduced by cannulating the artery with a side graft.

The axillary artery is often fragile, so direct cannulation can be traumatic. Also, closure of the axillary artery arteriotomy after direct cannulation is difficult and can result in axillary artery narrowing. Cannulation with a side graft avoids both problems. The axillary artery is rarely injured during side graft anastomosis, and decannulation is simply performed by transecting it and oversewing and clipping its stump.

No patient in this series who underwent axillary artery cannulation with a side graft experienced an intraoperative aortic dissection, whereas 3 (2%) patients undergoing direct cannulation did. This is a devastating complication of peripheral arterial cannulation (femoral or axillary), believed to arise when an intimal flap develops during cannula insertion. The dissection progresses when arterial perfusion through the cannula is begun. By perfusing through an anastomosed side graft, risk of intraoperative aortic dissection should be reduced; in this series, it was importantly reduced.

Because of these findings, our preference is to cannulate the axillary artery with a side graft when the ascending aorta is not suitable for cannulation. A limitation of cannulation with a side graft is that it requires more time than direct cannulation. Therefore, in unusual situations of hemodynamic instability, direct cannulation may be preferable.

Limitations
A limitation of this study is the temporal relationship of patients undergoing direct and side graft cannulation. Although there was some overlap in time, most patients undergoing direct cannulation were early in the series, and most patients having cannulation with a side graft were late in the series. Therefore, we were more experienced with axillary artery cannulation in patients who underwent cannulation with a side graft. Although we believe it unlikely, it is possible that our greater experience with axillary artery cannulation, and not the cannulation technique, accounts for the decreased morbidity observed in patients undergoing a side graft procedure.

Another limitation of this study is that it is an observational clinical study and not a randomized trial. Although we have tried to eliminate the effect of selection bias on outcomes by using propensity matching, we may not have accounted for all variables that resulted in patients being chosen for either direct or side graft cannulation. Therefore, patient factors, not cannulation technique, may be responsible for the lower morbidity observed in the side graft cannulation patients.

Conclusions
Axillary artery cannulation is safe and reliable in patients with ascending aortic disease. Complications are rare, and their occurrence can be substantially reduced with use of a side graft. Routine use of a side graft when cannulating the axillary artery is recommended.


   Appendix
 


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D.M. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-891.[Abstract]
  2. Breiman L. Bagging predictors. Mach Learn 1996;24:123-140.
  3. Blackstone E.H. Breaking down barriers: helpful breakthrough statistical methods you need to understand better. J Thorac Cardiovasc Surg 2001;122:430-439.[Free Full Text]
  4. Parsons LS. Reducing bias in a propensity score matched-pair sample using greedy matching techniques. In: Proceedings of the Twenty-Sixth Annual SAS Users Group International Conference. Cary, NC: SAS Institute, Inc, 2001:214–26
  5. 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]
  6. Neri E., Massetti M., Capannini G., et al. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999;118:324-329.[Abstract/Free Full Text]
  7. Blauth C.I., Cosgrove D.M., Webb B.W., et al. Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery. J Thorac Cardiovasc Surg 1992;103:1104-1112.[Abstract]
  8. Price D.L., Harris J. Cholesterol emboli in cerebral arteries as a complication of retrograde aortic perfusion during cardiac surgery. Neurology 1970;20:1209-1214.[Free Full Text]
  9. Borst H.G. Organ ischemia. In: Borst H.G., ed. Surgical treatment of aortic dissection, 1st ed Philadelphia: WB Saunders, 1996:249-272.



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