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Ann Thorac Surg 2004;78:103-108
© 2004 The Society of Thoracic Surgeons
a Departments of Cardiothoracic Surgery and Biomathemathics, The Mount Sinai Medical Center, New York University, New York, New York, USA
Accepted for publication January 22, 2004.
* Address reprint requests to Dr Strauch, Mount Sinai School of Medicine, Department of Cardiothoracic Surgery, One Gustave L. Levy Place, PO Box 1028, New York, NY 10029, USA
e-mail: ju.strauch{at}gmx.de
Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.
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Abstract |
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METHODS: Between 1999 and 2003, 284 patients with a mean age of 62.2 years (25 to 85), underwent axillary artery cannulation using a right angle wire-reinforced catheter. During this interval, attempted axillary cannulation was abandoned in only 14 patients because of inadequate backflow or other complications. Eighty-five patients were female. Severe aortic arteriosclerosis or degeneration was present in 209, aortic dissection in 63, and Marfan disease or aortitis in 12. The Bentall procedure was done in 144 patients, arch replacement in 86, the Yacoub procedure in 18, thoracoabdominal aneurysm repair in 16, and coronary artery bypass grafting in 20. Reoperations were at 30.2%.
RESULTS: Adverse outcome (hospital death or permanent stroke) occurred in 6.6% (n = 19). Thirteen patients (4.6%) died before hospital discharge, and 13 patients (4.6%; 9 of whom died) suffered permanent stroke. Transient neurologic dysfunction occurred in 9.2% (n = 26). Mean duration of hypothermic circulatory arrest, used in 246 patients, was 26 ±7 minutes. Mean duration of antegrade cerebral perfusion, used in 139 patients, was 47 ± 23 minutes. In 93%, the right axillary artery was cannulated. Complications included 2 cases (0.7%) of brachial plexus injury (one transient), and 3 (1%) of localized dissection.
CONCLUSIONS: Our results suggest that axillary artery cannulation, successful in 95% of patients, may be the optimal technique for reducing perfusion-related morbidity and adverse outcome in operations for acute dissection, atherosclerotic, and degenerative aneurysmal disease. It deserves serious consideration in all patients older than 65 requiring cardiopulmonary bypass.
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Introduction |
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The oldest and simplest cerebral protection technique is hypothermic circulatory arrest (HCA), which facilitates operation by providing a bloodless field. But HCA alone may not provide adequate global cerebral protection if the operation is prolonged, resulting in temporary neurologic deficits (TND) [1]. Retrograde cerebral perfusion was, and still is, used by some groups as an adjunct to HCA to enhance cerebral protection during thoracic aortic surgery. It remains unclear whether retrograde cerebral perfusion provides effective cerebral perfusion, metabolic support, washout of embolic material, and improved neurologic and neurophysiologic outcome [2].
This has led to the increasing use of selective antegrade cerebral perfusion, which allows unhurried repair of these often complex lesions. The cause of most major cerebral insults following ascending aorta-aortic arch surgery is not inadequate global cerebral protection, but stroke; its risk is not diminished, and may even be increased, when selective cerebral perfusion is utilized. The need to cannulate arterial vessels and to manipulate often severely diseased atherosclerotic aneurysms enhances the potential for embolization into the cerebral circulation, resulting in focal lesions and often neurologic injury.
The incidence of stroke after replacement of the aortic arch and ascending aorta is known to be influenced by the site of cannulation for cardiopulmonary bypass (CPB) and by perfusion technique. The preferred site of cannulation for CPB is usually in the ascending aorta, but this sometimes poses an unacceptable risk. When the ascending aorta is unsuitable for cannulation, the femoral artery is the most common alternative. But retrograde flow in a severely atherosclerotic and diseased aorta poses major risks, including dislodgement of plaques and aortic dissection, both of which may lead to cerebral, as well as peripheral, injury [3–5].
For these reasons, cannulation of the axillary artery has become increasingly widespread. Axillary artery cannulation preserves antegrade flow in the descending aorta while eliminating some of the risks associated with direct cannulation of the ascending aorta. It lowers the potential for embolization into right-sided cerebral vessels by perfusing them with flow which has not transversed the arch, and avoids the "sandblast" effect of turbulent flow from a catheter tip close to atherosclerotic lesions in the ascending aorta or aortic arch, and thus also reduces the risk of embolization into the left-sided cerebral vessels. Arterial inflow through the axillary artery increases the ease of using selective cerebral perfusion during the arch repair, which allows the surgeon to construct open proximal and distal anastomoses while the lower body is kept hypothermic during circulatory arrest.
A number of reports describing axillary artery cannulation in a small number of patients have appeared. We have been using axillary artery cannulation routinely since 1999, and report our experience in 284 patients.
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Patients and methods |
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Preoperative risk factors included: hypertension in 214 (75%) patients, coronary artery disease in 127 (45%), diabetes in 53 (19%), and chronic obstructive pulmonary disease (COPD) in 51 (18%). Thirty percent (n = 86) of the patients had previously undergone procedures that required sternotomy; the Bentall procedure had previously been carried out in 27 patients, and 43 had previously undergone aortic or mitral valve replacement.
Mean total CPB duration was 228 ± 58 minutes. Mean duration of hypothermic circulatory arrest, used in 246 patients, was 26 ± 7 minutes. Mean duration of antegrade cerebral perfusion, used in 139 patients, was 47 ± 23 minutes. The lowest mean esophageal temperature during selective cerebral perfusion (SCP) was 11.8°C ± 2.3°C (range, 9.8°C to 19.9°C); the mean bladder temperature was 15.2°C ± 3.6°C (range, 11.0°C to 25.7°C). Monitoring of cerebral venous oxygen uptake in the jugular venous bulb was successful in 259 (91%) patients. The mean length of postoperative hospital stay was 14.3 days (range, 5 to 85), and mean duration of intensive care unit stay was 3.9 days (range, 1 to 38).
Analysis of results
The overall results are described in terms of adverse outcome (AO), defined as in-hospital death or occurrence of permanent neurologic injury. A stroke was considered permanent if the patient was discharged with residual neurologic symptoms. Temporary neurologic dysfunction, including prolonged postoperative obtundation or confusion, as defined previously, was assessed in all patients surviving operation without stroke.
As outlined in a recently published study [5], there are a number of important preoperative and intraoperative variables that emerge as important independent risk factors for adverse AO after elective ascending aorta and aortic arch surgery: the presence of diabetes, arteriosclerosis od dissection as the etiology of the aneurysm, female gender, the presence of coronary artery disease, and a prolonged total cerebral protection time. Multivariate equations derived from electively operated patients studied retrospectively now allow us to calculate, prospectively, the risk for AO for each individual contemplating elective surgery and in whom these risk factors are known. To try and determine whether the use of axillary artery cannulation was likely to have been of benefit to the patients in the current study, we calculated the predicted risk for AO in the subset of 214 patients in this group who underwent elective ascending aorta (proximal repair) or elective aortic arch replacement (arch repair). We then compared the predicted with the actual outcomes in these patients.
We also compared the outcomes of the elective aneurysm patients in the subset for whom AO could be predicted with the results for the group as a whole. For the relatively few patients in whom axillary artery cannulation proved unsuccessful, we looked at whether there were any characteristics that made them different from the group in which axillary artery cannulation was successfully utilized.
Technique for axillary artery cannulation
Arterial pressure is routinely measured with a left radial artery cannula. Before the median sternotomy, with the patient in a supine position, a 6 to 8 cm transverse skin incision is made approximately 1 cm below the middle and lateral part of the right clavicle (deltopectoral groove). Following the direction of its fibers, the pectoralis major muscle is separated, and the underlying pectoralis minor muscle retracted laterally. The axillary artery is identified by palpation and then gently mobilized by sharp dissection without touching the medial and lateral brachial plexus cords posterior to the artery. The artery is then controlled with loops of silicone elastomer tape.
After the administration of heparin, the axillary artery is occluded distally with a silastic vessel loop, and a transverse arteriotomy is carried out. The axillary artery is then cannulated directly using a 20F to 26F wire-reinforced right angled flexible cannula (axillary access arterial cannula, Edwards Lifescience LLC, Irvine, CA [see Fig 1]). After proximal clamp removal, the cannula is advanced 3 cm into the artery, and the snare on the silastic vessel tape is tightened. The cannula is held in place by a ligature on the snare and a skin stitch at the lateral end of the incision. Free backflow of blood is assured before perfusion is initiated. At the end of the procedure, the artery is repaired with 7 to 0 polypropylene continuous suture.
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Overall outcome
Adverse outcome (hospital death or permanent stroke) occurred in 19 of 284 (6.6%) patients. Thirteen (4.6%) patients died before hospital discharge, and 13 (4.6%) patients, 9 of whom died, suffered permanent stroke. Postoperative transient neurologic dysfunction occurred in 26 of 225 (9.2%) patients.
Using equations for predicting the risk of adverse outcome after ascending aorta or aortic arch operations in patients operated on electively [6], we found that a significantly lower number of deaths and strokes than predicted occurred in the 214 patients operated on electively using axillary artery cannulation (Table 1). Fifteen patients in this series experienced AO, instead of the 35 predicted (p = 0.0002). In the group of 144 patients undergoing elective proximal operations, 21 instances of AO were predicted, but only 7 patients actually experienced AO (p less than 0.001). The number of observed cases of AO for elective arch repair was 8; also lower than the 14 predicted. This difference failed to reach statistical significance (Table 1). The overall rate of AO in the subgroup of elective patients in this series (15 of 214, 7%) was not significantly different from the rate of AO observed in the group as a whole with the urgent and emergent cases (19 of 284, 6.6%).
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Unsuccessful cannulation
During the reported time period, attempted cannulation was successful in all but 12 (4.2%) patients, in whom inflow from the pump had to be shifted to an alternative site because of complications such as dissection or inadequate backflow from the brachiocephalic artery (see Table 2).
If right axillary artery cannulation failed, left axillary artery cannulation was usually attempted before an alternative site was chosen.
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In 3 (1%) patients, dissection made cannulation impossible. The localized dissection occurred in one of the 3 patients during arteriotomy, in one during preparation, after encircling the axillary artery with silastic tapes, and in another patient after installing perfusion. One patient underwent localized repair with or without vascular patching, and in one patient with Marfan syndrome, the artery was ligated; no distal perfusion deficits were observed postoperatively. Cannulation was successfully carried out subsequently in the midascending aorta in these two patients.
A third patient, at the initiation of the perfusion, suffered dissection of the axillary, subclavian, and innominate arteries extending into the adjacent arch. Flow was discontinued, and the cannula switched to the femoral artery. A small localized dissection was evident on computed tomographic scans one and two years later.
In one (0.4%) patient, the axillary artery could not be used for cannulation owing to its unusual anatomical position beneath the clavicle on the right side. In one (0.4%) patient the internal diameter of the axillary artery was too small for cannulation and the incision was closed. In one (0.4%) last patient, the axillary artery was found upon opening to be involved in a chronic type A aortic dissection and cannulation was not done, for fear of malperfusion.
Patients with technique-related complications
The 14 patients with technique-related complications had a median age of 61.9 (37 to 80) years, a majority were of male gender (79%), with arteriosclerosis as the leading etiology of disease (86%): these patients were therefore comparable to those in whom axillary artery cannulation was successfully carried out. All the technique-related axillary artery complications occurred in elective cases. The incidence of reoperation in patients with technique-related axillary artery complications was the same as in the group of patients with technique-related complications and the group without complications together. Similarly, intraoperative factors such as HCA and SCP duration were also not very different from those of the entire patient group. There were no cases of permanent stroke or deaths (AO) in this subcategory of 14 patients. One patient showed signs of TND.
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Comment |
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Postoperative permanent neurologic deficits after aortic arch operations usually result from cerebral emboli, and are unlikely to be influenced by the method of cerebral protection unless the operation is very prolonged [1, 8]. Several of the important risk factors for adverse outcome include patient characteristics, which cannot be addressed by improvements in surgical technique including age, gender, and the presence of diabetes or chronic obstructive pulmonary disease. Among the important variables that have been identified as influencing the occurrence of postoperative stroke following aortic arch repair, which might be affected by the method of cannulation are the presence of clot and atheroma in the aorta [1], and dissection as the etiology of the aneurysm.
Direct axillary artery cannulation was first described by Villard and co-workers in 1976, but was subsequently only rarely utilized until the Cleveland Clinic group published a report with the results in 35 patients [4, 9] (see Table 3). Table 3 is a summary of published reports of the use of this technique. The major advantage of axillary artery cannulation is that the risk of cerebral atheroembolization is diminished even though continuous blood flow to the brain is provided by means of selective cerebral perfusion, during steps where a bloodless field is required for the operation. The axillary artery has less atherosclerotic change than either the ascending aorta or the femoral artery, and can easily be exposed [3].
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We cannulated the axillary artery directly without a synthetic graft-to-artery anastomosis, using a 20F to 26F wire-reinforced right angled cannula. Direct cannulation is less time consuming, lowers the risk of bleeding, and is technically easier than performing graft-to-artery anastomosis. Moreover, use of an end-to side graft can result in hyperperfusion injury to the extremity unless the distal vessel is occluded. We discovered that placement of the cannula was feasible in almost all cases, even when the artery appeared fragile. The design of the cannula makes it impossible to advance it too far toward the common carotid artery, obviating the possible threat of obstruction to carotid artery flow, and possible cerebral ischemia as a consequence.
This series included a relatively high incidence (30%) of reoperations. We recommend axillary artery cannulation, with all its other advantages, especially for reoperations because of the safety it provides when entering the chest under these circumstances.
Good clinical results for axillary artery cannulation for various indications have previously been reported [3, 4, 6, 8, 14, 15]. Our favorable results with liberal use of axillary artery cannulation confirm these findings, with a low rate of complications and adverse outcome. None of the deaths were related to use of the axillary artery cannulation site. The stroke rate of 4.6% is still not ideal but this cohort of patients had a high potential for neurologic injury. In the subset of electively operated patients, the majority of patients in this series, the incidence of adverse outcome was significantly lower than predicted by a formula based on known independent risk factors for death and stroke following ascending aorta and aortic arch operations (Table 1).
The main local complications of axillary artery cannulation, which are described in the literature, are brachial plexus injury and axillary artery thrombosis [4, 5, 15]. Such complications related to the axillary cannulation occurred in only a few of our cases, including two brachial plexus injuries (one transient, and one due to localized dissection). Of several lymphoceles, two required aspiration and the rest resolved without intervention. There were no instances of bleeding, wound infection, or distal vascular compromise.
Axillary artery cannulation may be for the previous reasons; the ideal cannulation site for patients undergoing CABG in whom the ascending aorta is severely atheromatoous and calcified. It is now being used, in our institution, in numerous patients more than 65 years of age undergoing routine procedures requiring cardiopulmonary bypass.
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Conclusion |
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsCommentConclusionDiscussionReferences |
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And then also, what arm do you have the anesthesiologist put your arterial line in on these patients?
DR STRAUCH: Thank you very much for your questions. For your second question, the arterial line is inside the left side radial artery because routinely the right axillary was cannulated and therefore was clamped distally during the period of perfusion. For your first question, we never used a graft sewed to the artery. We always used direct cannulation, and while on distal occlusion, there were no problems with hyperperfusion of the arm as well as hypoperfusion signs postoperatively.
DR TOMAS D. MARTIN (Gainesville, FL): Just a comment. We have used it very minimally, but we have sewn the side arm graft and found no problem with that and no dissection, no problem with the artery. A second comment. You say that this may be the cannulation technique of choice, but I just want to get your comments. Even in this meeting, there are two other presentations on arch aneurysms, both of which have a similar neurologic deficit rate, one by Dr Svensson, who presented earlier with a 6% neurologic deficit rate, and one to be presented tomorrow by Dr Beaver and in the aprotinin group had a 4% neurologic deficit rate, and all these were done with cannulation either in the groin or in the ascending aorta.
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J. M. Budde, D. L. Serna Jr, S. C. Osborne, M. A. Steele, and E. P. Chen Axillary Cannulation for Proximal Aortic Surgery is as Safe in the Emergent Setting as in Elective Cases Ann. Thorac. Surg., December 1, 2006; 82(6): 2154 - 2160. [Abstract] [Full Text] [PDF]
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P. P. Urbanski, A. Lenos, Y. Lindemann, E. Weigang, M. Zacher, and A. Diegeler Carotid artery cannulation in aortic surgery J. Thorac. Cardiovasc. Surg., December 1, 2006; 132(6): 1398 - 1403. [Abstract] [Full Text] [PDF]
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F. Dagenais, R. Shetty, J.-P. Normand, R. Turcotte, P. Mathieu, and P. Voisine Extended Applications of Thoracic Aortic Stent Grafts Ann. Thorac. Surg., August 1, 2006; 82(2): 567 - 572. [Abstract] [Full Text] [PDF]
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S. A. LeMaire, S. A. Carter, I. V. Volguina, A. T. Laux, D. M. Milewicz, G. W. Borsato, C. K. Cheung, J. Bozinovski, J. M. Markesino, W. K. Vaughn, et al. Spectrum of Aortic Operations in 300 Patients With Confirmed or Suspected Marfan Syndrome Ann. Thorac. Surg., June 1, 2006; 81(6): 2063 - 2078. [Abstract] [Full Text] [PDF]
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Y. Moizumi Reply Ann. Thorac. Surg., June 1, 2006; 81(6): 2340 - 2341. [Full Text] [PDF]
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K. Kurisu, Y. Ochiai, M. Hisahara, K. Tanaka, T. Onzuka, and R. Tominaga Bilateral Axillary Arterial Perfusion in Surgery on Thoracic Aorta Asian Cardiovasc Thorac Ann, April 1, 2006; 14(2): 145 - 149. [Abstract] [Full Text] [PDF]
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 G. Silvay and M. E. Stone Repair of Thoracic Aneurysms, with Special Emphasis on the Preoperative Work-Up Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2006; 10(1): 11 - 15. [Abstract] [PDF]
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C. Olsson and S. Thelin Antegrade Cerebral Perfusion With a Simplified Technique: Unilateral Versus Bilateral Perfusion Ann. Thorac. Surg., March 1, 2006; 81(3): 868 - 874. [Abstract] [Full Text] [PDF]
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F. Santini, G. Montalbano, A. Messina, A. D'Onofrio, G. Casali, F. Viscardi, G. B. Luciani, and A. Mazzucco Survival and quality of life after repair of acute type A aortic dissection in patients aged 75 years and older justify intervention Eur. J. Cardiothorac. Surg., March 1, 2006; 29(3): 386 - 391. [Abstract] [Full Text] [PDF]
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K. Matsuura, H. Ogino, H. Matsuda, K. Minatoya, H. Sasaki, T. Yagihara, and S. Kitamura Surgical Outcome of Aortic Arch Repair for Patients With Takayasu Arteritis Ann. Thorac. Surg., January 1, 2006; 81(1): 178 - 182. [Abstract] [Full Text] [PDF]
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K. Matsuura, H. Ogino, H. Matsuda, K. Minatoya, H. Sasaki, T. Yagihara, and S. Kitamura Multivariate analysis of predictors of late stroke after total aortic arch repair Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 473 - 477. [Abstract] [Full Text] [PDF]
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F. Lakew, P. Pasek, M. Zacher, A. Diegeler, and P. P. Urbanski Femoral Versus Aortic Cannulation for Surgery of Chronic Ascending Aortic Aneurysm Ann. Thorac. Surg., July 1, 2005; 80(1): 84 - 88. [Abstract] [Full Text] [PDF]
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S. A. Kucuker, M. A. Ozatik, A. Saritas, and O. Tasdemir Arch repair with unilateral antegrade cerebral perfusion Eur. J. Cardiothorac. Surg., April 1, 2005; 27(4): 638 - 643. [Abstract] [Full Text] [PDF]
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F. F. Immer, U. Hagen, P. A. Berdat, F. S. Eckstein, and T. P. Carrel Risk factors for secondary dilatation of the aorta after acute type A aortic dissection Eur. J. Cardiothorac. Surg., April 1, 2005; 27(4): 654 - 657. [Abstract] [Full Text] [PDF]
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A. L. Estrera, Z. Garami, C. C. Miller III, R. Sheinbaum, T. T.T. Huynh, E. E. Porat, B. S. Allen, and H. J. Safi Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 277 - 285. [Abstract] [Full Text] [PDF]
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