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Ann Thorac Surg 2007;83:1219-1224
© 2007 The Society of Thoracic Surgeons

Review

Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation?

Helmut Gulbins, MD*, Anita Pritisanac, MD, Jürgen Ennker, MD

Department of Cardiac Surgery, Heart Center Lahr, Lahr/Schwarzwald, Germany

* Address correspondence to Dr Gulbins, Department of Cardiac Surgery, Heart Center Lahr, Hohbergweg 2, 77933 Lahr/Schwarzwald, Germany (Email: helmut.gulbins{at}heart-lahr.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
There is a trend towards cannulation of the axillary artery for extracorporeal circulation in patients requiring aortic arch surgery. We analyzed the published data comparing axillary and femoral cannulation for safety and outcome. End points were death; stroke, neurologic, and vascular complications; and malperfusion. Femoral cannulation is safe for extracorporeal circulation in patients without aortic arch surgery. In patients with type A dissections, malperfusion may occur owing to retrograde perfusion of the false lumen and subsequent occlusion of the origin of the supra aortic vessels. Cannulation of the axillary/subclavian artery results in antegrade flow, at least in the right carotid artery, with the possibility of antegrade cerebral perfusion during aortic arch repair. There was a trend towards improved neurologic outcome when the axillary artery was used for extracorporeal circulation in such patients. When different techniques were compared, the use of a side graft for axillary cannulation reduced the complication rate. The lack of randomized trials and the high variety of inclusion criteria in the different studies do not allow a general recommendation for the use of the axillary artery as cannulation site.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
For a long time, the femoral artery has been used as arterial cannulation site for extracorporeal circulation. A low complication rate was reported [1, 2]. With the routine use of the ascending aorta as an arterial cannulation site [2, 3], the femoral artery was used only in complicated cases when aortic cannulation was deemed not to be feasible, such as with aortic dissection or aortic arch surgery. Retrograde dissection [4], malperfusion of the true lumen [5], and an increasing evidence for the benefits of antegrade cerebral perfusion during aortic arch surgery [6–9] resulted in the search for an alternative in such cases. The axillary artery was described as a safe and easy cannulation site for extracorporeal circulation, especially in patients with a diseased ascending aorta [10–16]. Whether the axillary artery should be used routinely in aortic arch surgery is discussed controversially. In this review, we present our analysis of the literature dealing with femoral or axillary cannulation.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
The literature was reviewed for publications reporting techniques, results, and complications with femoral or axillary cannulation, or both, in aortic surgery. The key words used were axillary cannulation, (acute) aortic dissection, femoral cannulation, aortic arch surgery, antegrade cerebral perfusion, extracorporeal circulation, and perfusion. Only publications with more than 10 patients reported, or case reports about severe complications with the techniques, were included in the analysis.

The main end points were death; stroke, neurologic, and vascular complications; and malperfusion. Because the study populations lacked homogeneity, the results are summarized and given as numbers and percentage. An overview over the cumulative results is given in Table 1, and the most important studies cited in the text are listed in Table 2 [17–27].


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  		Table 1 Summary of the Analyzed Reports in the Literature
 

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  		Table 2 Cited Studies With the Largest Patient Numbers Describing the Techniques or Comparing Different Cannulation Techniques
 

   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Femoral Cannulation
The femoral artery was used as the primary cannulation site for extracorporeal circulation in cardiac surgery for a long time [1, 2]. The avoidance of direct manipulations of the ascending aorta and the good access to the vessel were the main advantages. In large series, the safety of this method was proven with a low incidence of complications reported in elective cases.

In patients with acute dissections, the retrograde perfusion was found to cause complications such as cerebral malperfusion [4, 5, 28]. At least latent cerebral malperfusion is often present in patients with acute type A aortic dissection. The cerebral malperfusion is caused by dissections of the cerebral vessels themselves or by compression of the origin of these vessels by the false lumen. In the latter case, this effect might be complicated by retrograde perfusion. It can therefore be difficult to distinguish between sequelae of the femoral cannulation with retrograde perfusion and malperfusion caused by the underlying disease itself [29].

Local complications such as neuronal damage or malperfusion of the leg were rare [30] and were mainly caused by technical errors such as damaging neuronal structures or lymphatic vessels. The latter results in local lymphatic fistulas, which are usually treated by compression and rarely demand surgical revision. With increasing experience, however, direct aortic cannulation proved superior to femoral cannulation in low-risk patients with no aortic pathology [2, 3].

For patients with aortic arch pathology, hypothermic circulatory arrest with femoral cannulation remained the gold standard for a long time [31, 32]. When this technique is used, a circulatory arrest period of 20 to 30 minutes is usually regarded as safe, although no true cutoff point can be defined [31, 32]. Good results with this technique were reported even in octogenarians [33]. After replacement of the aortic arch, cannulation was changed and antegrade perfusion through the vascular prosthesis was reassumed for rewarming. Although femoral cannulation was possible in most of the patients, the issue of retrograde aortic perfusion with possible malperfusion of the brain remained. The low incidence of complications [1, 2], however, made it difficult to justify another cannulation site.

In recent years, antegrade cerebral perfusion was introduced to reduce neurologic damage in aortic arch surgery [18, 34–36]. Evidence is increasing that neurologic outcome is improved [18], but the inhomogeneity of the study populations and the variety of techniques described make statistical analyses very difficult. In a large series of more than 700 patients, Hagl and coworkers [6] failed to show a reduced stroke incidence but gave evidence for significantly fewer minor neurologic disorders.

Axillary Cannulation
In the late 1990s, axillary cannulation was introduced as the cannulation site of choice in reoperations, aortic calcification, and aortic arch pathology [12–16, 20, 37–42]. This was deemed necessary owing to increased patient numbers with these comorbidities and vascular diseases that made femoral cannulation difficult or even impossible. In addition, the use of this arterial vessel allowed antegrade cerebral perfusion even in patients with aortic dissections or aortic arch pathology.

In the first series, the axillary artery was used instead of the femoral artery because of peripheral vascular disease or severe aortic atheromatosis [12–16]. Sabik and colleagues [12] reported good results with axillary artery cannulation in 35 cases. Their patients experienced no neurologic events and no vascular complications. In these studies, however, the axillary artery was used as a second choice when no other cannulation site seemed to be suitable for perfusion. Baribeau and colleagues [15] reported about 29 patients. They also described indirect cannulation using an 8-mm vascular prosthesis as inflow in 18 of these patients, but reported no differences between direct and indirect cannulation technique.

With regard to the possibility of antegrade cerebral perfusion during hypothermic circulatory arrest, the axillary artery was used more often in patients with aortic arch pathology or aortic dissections. Because antegrade cerebral perfusion was supposed to improve neurologic outcome in such patients [6, 18, 34, 35], this cannulation site provided antegrade cerebral blood flow during the whole procedure of aortic arch surgery. More and more groups subsequently used the axillary or subclavian artery in patients with aortic arch pathology or acute type A dissections [20, 26, 37, 41, 42]. These experiences showed a trend towards improved outcome, especially for neurologic damage, but provided very inhomogeneous study populations and operative techniques.

With increasing experience with axillary cannulation, the number of complications reported also increased. Although rare, the local complications were similar to those observed for the lower extremity when the femoral artery was used. Intraoperative dissection of the innominate artery and the aortic arch originating from the axillary cannulation site was reported [43, 44], and other groups described local vascular and neuronal damage [19, 22]. The local technical issues led to different operative strategies.

The main two techniques described were direct cannulation of the axillary or subclavian artery [41, 42] or the use of a side graft [15, 16, 44], which was either synthetic or an autologous vein [45]. Strauch and colleagues [42] reported 14 local complications in 284 patients (4.9%) with direct cannulation, a quite high rate compared with femoral cannulation. The local complication rate, however, was reduced by the use of a side graft for axillary/subclavian cannulation, as reported by Sabik and colleagues [21]. Other studies comparing the mentioned techniques also showed fewer local complications when a side graft was used [19, 21, 23].

With sophisticated surgical technique and the use of a side graft, the axillary/subclavian artery can also be used for a second time in redo cases [46, 47], making it a true alternative to the femoral artery in such complex situations.

Axillary and Femoral Cannulation in Aortic Arch Surgery
Studies comparing femoral and axillary cannulation report improved outcome, especially for neurologic damage [7, 8, 26, 24]. Their results (Table 1) show a clear trend towards fewer neurologic events in the axillary artery group; however, the differences in the reported techniques, patient selection, and outcome presentation do not allow a detailed statistical analysis. The literature search found no randomized trials to date, and all studies the compared historic patient collectives in a retrospective fashion. In addition, the rather low number of patients included in each study precludes detailed statistical analysis.

Studies published in 2003 and 2004 report on the safety and outcome with femoral cannulation. Fusco and colleagues [25] demonstrated the safety of femoral cannulation in patients with type A dissections, although they also used the axillary artery in 2 patients in whom femoral cannulation was not possible. Tan and colleagues [17] reported a relatively high perioperative mortality of 25% in 252 patients with type A dissection and an incidence of neurologic events of 22.7%. In their analysis, poor outcome was not determined by the cannulation side but by the preoperative situation of the patient.

Most authors still use deep hypothermia despite antegrade perfusion through the axillary artery. This technique is probably preferred because it has a longer time frame for a complete circulatory arrest in case it is necessary. With antegrade perfusion using the axillary artery, aortic arch repair can be done under moderate hypothermia [27, 48–50] during circulatory arrest of the body perfusion. With this strategy, hypothermia is necessary for protection of all other organs during aortic arch surgery while the brain is still perfused. Different intraluminal perfusion catheters were used in this setting for antegrade cerebral perfusion; because of the possible malpositions of these catheters [51], the axillary artery use is of clear advantage.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
All cited studies compare historical, more or less consecutive series of patients. An additional bias may occur when both techniques are used in a single center: more experienced surgeons will be more likely to use the axillary artery, whereas others may prefer the femoral artery to be on the safe side. The different individual situations in which patients with type A dissection present at the time of surgery demands an individual approach, and the missing homogeneity of this population makes it difficult to relate outcome to a single variable such as cannulation site [32, 32]. The emergency situation, which is frequent in these cases, often does not allow for sophisticated surgical techniques, but requires a quick, safe, and simple approach to establish extracorporeal circulation, body perfusion, and the possibility for cooling.

In addition, hypothermia is a proven technique for organ preservation, and even a cerebral damage can be minimized when the brain is cooled before normal perfusion is restored. Therefore, patients with type A dissections are not suitable for any prospective, randomized trials, and the number of patients of each center is rather small. Multicenter approaches cannot be realized easily owing to the different strategies used in different centers, thus reducing the comparability of the results.

Patients with true aneurysms of the aortic arch or a calcified ascending aorta/aortic arch represent a completely different population. In these cases, an elective situation allows for a standardized approach with more sophisticated surgical strategies. Because these patients normally do not present with such an urgent case, every effort must be made to reduce the perioperative risk for stroke or other complications.

In elective cases, direct aortic cannulation is another alternative to femoral or axillary cannulation. Epiaortic echo scanning can be used to examine the ascending aorta for atherosclerotic or calcified plaques, thus increasing the safety of this cannulation site. The results of this technique cannot be compared with the studies of axillary cannulation, because in most of these studies, a diseased ascending aorta was the reason for choosing the axillary artery. The advantage of direct aortic cannulation compared with routine femoral cannulation in elective cases was shown in large retrospective analyses [2].

The trend toward fewer neurologic events in the axillary artery group seems to be attributable to the antegrade perfusion of the brain, thus avoiding complete circulatory arrest or reducing it to a minimal time frame. Because the safety of deep hypothermic circulatory arrest does not have a true cutoff point, the results of the procedure are not always predictable. In addition, deep hypothermia has great influences on all organ systems because all organ functions of the human body are optimized at 36.9°C. Deep hypothermia is, therefore, a most invasive technique affecting all functions of the body.

Another source of neurologic damage in aortic surgery is emboli originating from the diseased aorta. When the femoral artery is used, a reversed flow direction results through the descending aorta that can cause embolization of atherosclerotic plaque material into the supra aortic vessels and result in brain damage or stroke. When the ascending aorta is used to establish perfusion, atheromatous plaques can be embolized from the ascending aorta mainly into the innominate artery. Hedayati and coworkers [48] showed in an animal model that axillary cannulation reduced cerebral microemboli significantly. This effect also contributes to the improved neurologic outcome when the axillary/subclavian artery was used.

The data published by Touati and colleagues [52] recently demonstrated that in cases with aortic arch pathology, complete antegrade perfusion of the innominate and left carotid artery is possible without the need for deep hypothermic circulatory arrest. This reduced the invasiveness of these procedures. The application of these techniques to surgery of the descending aorta might also reduce mortality in these patients. More experience with this strategy is required to answer the questions concerning safety and reproducibility with larger series. This strategy seems to offer reduced invasiveness, especially in patients with aneurysms of the ascending aorta and the aortic arch who undergo elective operations, thus possibly reducing morbidity and mortality in these cases.

The superior results of axillary cannulation compared with femoral cannulation seem to be caused by the maintenance of antegrade cerebral blood flow through the whole procedure. Avoiding complete circulatory arrest especially reduced minor neurologic events. Despite this advantage, complications such as dissection of the innominate artery and malperfusion during extracorporeal circulation also occur. The lack of any randomized prospective trials does not allow a general recommendation of the axillary artery to be the new cannulation side of choice in patients with aortic arch pathology.[50,51]


   References
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 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
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