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Ann Thorac Surg 2005;79:2163-2165
© 2005 The Society of Thoracic Surgeons

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Extracorporeal Membrane Oxygenation With Right Axillary Artery Perfusion

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio

Accepted for publication January 14, 2004.

^_* Address reprint requests to Dr Navia, Department of Thoracic and Cardiovascular Surgery, F25, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH44195 (E-mail: naviaj{at}ccf.org).

	Abstract

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Extracorporeal membrane oxygenation can be instituted through various cannulation sites. This paper describes a technique for axillary artery cannulation for inflow perfusion in extracorporeal membrane oxygenation and discusses both potential advantages and limitations. Exposure of the artery was achieved through the deltoid-pectoral approach. Both direct cannulation and interposition graft cannulation are possible, but the latter is preferred. Advantages of axillary artery cannulation are related mainly to the establishment of "central" support with antegrade flow and excellent upper body oxygenation. It also affords chest closure after postcardiotomy shock, and easy control of any mediastinal bleeding. These cannulation sites may be options for the institution of venoarterial extracorporeal membrane oxygenation, especially in postcardiotomy and respiratory failure patients and in patients with significant peripheral vascular disease.

	Introduction

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Extracorporeal membrane oxygenation (ECMO) has been used successfully in neonatal cardiopulmonary support, adult respiratory distress syndrome, adult postcardiotomy shock, and as a bridge to a left ventricular assist device or heart and lung transplantation.

Venoarterial extracorporeal perfusion is easily instituted by means of central cannulation (ascending aorta and right atrium or common femoral vein) and by various peripheral vessel cannulation techniques. The latter avoids the need for two sternotomies (cannulation and decannulation) and reduces the risk of bleeding and infection; however, limb ischemia and unsatisfactory upper body oxygenation are potential risks.

This paper describes a technique of axillary artery cannulation for inflow perfusion in ECMO and discusses both the potential advantages and limitations.

	Technique

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There are several choices of skin incisions for exposure of the right axillary artery. Baribeau and colleagues [1] prefer a more medial approach, claiming a lower risk of brachial plexus injury. Our preferred approach is the deltoideo-pectoral approach. The axillary artery is exposed for cannulation through a 6-cm to 8-cm incision, 2 cm below and parallel to the lateral two thirds of the clavicle. The pectoralis muscle is divided parallel to its fibers; the clavipectoralis fascia is incised, exposing the pectoralis minor, which is divided or retracted laterally. The axillary artery is identified by palpation and is usually superior to the vein. The brachial plexus is dissected from the artery. Proximal and distal control of the artery is gained by passing a shoestring tie around it. For cannulation, there are two options. If the artery is of good size and with good exposure, direct cannulation can be performed. A single 4–0 Prolene pursestring suture (Ethicon, Somerville, NJ) is placed in the anterior wall of the axillary artery and passed through a tourniquet. After heparin is administered, the artery is clamped with femoral clamps and a number 20 or 22 right-angle arterial cannula is inserted. Flow is evaluated by back-bleeding through the cannula.

In patients with a small body surface area and, therefore, small vessels (or if the artery is in unfavorable position), an 8-mm interposition Dacron graft is preferred. Arterial inflow through a Dacron graft provides advantages over direct cannulation of the axillary artery because it allows easy closure of the artery and permits normal perfusion of the arm. The same cannula is then connected to the distal graft. Care must be taken to avoid oozing from the graft that is between the tip of the cannula and the anastomosis with the axillary artery during the support. Two maneuvers are useful: one, make the interposition graft short, usually 6 cm to 8 cm; and two, advance the tip of the cannula as far as possible inside the graft until it almost reaches the axillary artery. The cannula is exteriorized by a small, more lateral second incision, where it is connected to the ECMO circuit (Fig 1). Hemostasis is revised; the incision is closed by layers, and sterile dressing is applied. Adequate perfusion is confirmed by transesophageal echocardiography and by blood pressure measurements in both radial arteries.

View larger version (90K): [in this window] [in a new window]   Fig 1. Interposition graft cannulation of the right axillary artery and exteriorization by a small second incision.

View larger version (47K): [in this window] [in a new window]   Fig 2. Extracorporeal membrane oxygenation circuit: venous inflow through the femoral vein, centrifugal blood pump with oxygenator, and arterial inflow through interposition graft over the right axillary artery.

From February 2001 through April 2003, 5 patients underwent axillary cannulation as part of the ECMO circuit. Indications for ECMO included postcardiotomy shock in 3 patients and acute respiratory failure in 2. Indications for axillary cannulation were lower extremity ischemia after venoarterial ECMO through the femoral artery in 2 and poor upper body oxygenation in 1 of the postcardiotomy patients. Inadequate oxygenation with venovenous ECMO was the indication in both respiratory failure patients. All patients but 1 underwent cannulation through an interposition 8-mm Hemashield graft (Boston Scientific Co, Natick, MA). One patient required reexploration for bleeding from the anastomotic site. No other complications related to the axillary cannulation were identified. Four patients were successfully weaned from ECMO between 3 days and 9 days of support. One patient died of sepsis 1 week later. The other patient was maintained on ECMO support for 20 days but subsequently died from multiple organ failure.

	Comment

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Axillary artery cannulation is a safe and effective method of arterial inflow during cardiopulmonary bypass in patients with severe atherosclerotic or aneurysmal disease. Although technically more difficult and time consuming, axillary artery cannulation provides antegrade flow in a vessel that is usually disease free. Indication criteria has been broadened based on studies that showed the feasibility and safety of the procedure [3]. Axillary artery insertions of an intraaortic balloon pump [4] and LVAD [5] have been described.

During venoarterial bypass for extracorporeal support, uniform distribution of the oxygenated blood to all parts of the body has been a major concern. Limitations of femoral artery perfusion have been sufficiently elucidated, and alternate routes have been explored. Carotid artery and brachial artery perfusion have been proposed as potential sites [6, 7]. Early experimental studies [8] have proven the effectiveness of right axillary artery perfusion in delivering oxygenated blood to cerebral circulation at all bypass levels. Therefore, the use of the right axillary artery as inflow in the ECMO circuit has several potential advantages: (1) it provides "central" support with antegrade flow and excellent upper body oxygenation; (2) it is technically easy and reproducible; (3) it is a safe procedure with low complication rates; (4) it may avoid cerebral embolization; (5) it allows closure of the chest after postcardiotomy shock, which makes hemorrhage easy to control and minimizes the risk of infection; (6) it avoids a second surgery (decannulation) by making the support independent from the chest closure; and (7) it avoids median sternotomy for central ECMO perfusion in medical respiratory failure patients.

An additional advantage of the right axillary artery approach over the femoral artery is wound healing. Use of the femoral artery carries potential complications such as limb ischemia, lymph fistula, nerve injuries, hematoma, or muscle weakness. The less prevalent complication of arm ischemia is also a great advantage over the femoral artery approach; the axillary artery benefits from rich collateral flow from the thyreocervical trunk to the suprascapular and transverse cervical arteries. This rare complication can be even more reduced by the routine use of an interposition graft. With a thorough knowledge of the anatomy and careful surgical technique, brachial plexus injury can be avoided and will be an uncommon complication. There are few contraindications to axillary artery cannulation, including extension of the aortic disease process into the artery and known axillary/subclavian stenosis. Morbid obesity is a relative contraindication, as exposure of the artery in these patients can be difficult.

The major disadvantage of right axillary artery cannulation is that it is a more time consuming procedure. This limits, if not eliminates, its use in an emergency (ie, cardiac or respiratory arrest). Moreover, it cannot be percutaneously performed as the femoral approach and, theoretically, increases the risk of infection.

In conclusion, axillary artery cannulation is feasible for ECMO support. It may be an option for the following: postcardiotomy patients; patients presenting with acute respiratory failure in the presence of important peripheral vascular disease (aortoiliac aneurysms, severe peripheral aortoiliac occlusive disease or arteriosclerosis of the femoral vessels); patients with limb complications related to femoral artery cannulation; and patients under peripheral ECMO support with inadequate upper body oxygenation and perfusion.

	References

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1. Baribeau YR, Westbrook BM, Charlesworth DC. Axillary cannulationfirst choice for extra-aortic cannulation and brain protection. J Thorac Cardiovasc Surg 1999;118:1153-1154.[Free Full Text]
2. McDonald M, Smedira NG. Adult extracorporeal life supportIn: Franco K, Verrier E, editors. Advanced therapy in cardiac surgery. Hamilton, ON: BC Decker; 1999. pp. 326-334.
3. Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary arteryan alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-890.[Abstract]
4. Blythe D. Percutaneous axillary artery insertion of an intra-aortic balloon pump Anesth Intens Care 1995;23:406-407.
5. Edmunds LH, Herrmann HC, DiSesa VJ, Ratcliffe MB, Bavaria JE, McCarthy DM. Left ventricular assist without thoracotomyclinical experience with the Dennis method. Ann Thorac Surg 1994;57:880-885.[Abstract/Free Full Text]
6. Soeter JR, Mamiya RT, Sprague AY, McNamara JJ. Prolonged extracorporeal oxygenation for cardiorespiratory failure after tetralogy correction J Thorac Cardiovasc Surg 1973;66:214-218.[Medline]
7. Hill JD, de Leval MR, Fallat RJ, et al. Acute respiratory insufficiencytreatment with prolonged extracorporeal oxygenation. J Thorac Cardiovasc Surg 1972;64:551-562.[Medline]
8. Wickline SA, Soeter JR, McNamara JJ. Oxygenation of the cerebral and coronary circulation with right axillary artery perfusion during venoarterial bypass in primates Ann Thorac Surg 1977;24:560-565.[Abstract/Free Full Text]

This article has been cited by other articles:

				F. Capuano, T. H. Danesi, A. Roscitano, and R. Sinatra How to ensure a good flow to the arm during direct axillary artery cannulation Eur J Cardiothorac Surg, August 1, 2011; 40(2): 520 - 521. [Abstract] [Full Text] [PDF]

				F. A. Atik and J. L. Navia Reply Ann. Thorac. Surg., March 1, 2006; 81(3): 1178 - 1178. [Full Text] [PDF]

				M. Pocar, A. Moneta, R. Mattioli, and F. Donatelli Closed-Chest Transaxillary Venoarterial ECMO Ann. Thorac. Surg., March 1, 2006; 81(3): 1177 - 1178. [Full Text] [PDF]

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): José L. Navia Fernando A. Atik Erik A. Beyer Pablo Ruda Vega Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Navia, J. L. Articles by Ruda Vega, P. Search for Related Content PubMed PubMed Citation Articles by Navia, J. L. Articles by Ruda Vega, P. Related Collections Extracorporeal circulation