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uz Ta
dem
r, MDa
a Department of Cardiovascular Surgery, Akay Hospital, Buklum Sokak, No. 4 Kavaklidere, Ankara 06660, Turkey
b Department of Anesthesiology, Akay Hospital, Buklum Sokak, No. 4 Kavaklidere, Ankara 06660, Turkey
(Email: otasdemir{at}superonline.com).
We have read with interest the review article comparing axillary cannulation with femoral cannulation for aortic surgery [1]. In our opinion, there are some missing points in this article, and we have some comments.
The authors only described the axillary and the subclavian artery as the main cannulation sites for antegrade cerebral perfusion (ACP) [1]. The publications with more than 10 patients were included in this analysis. Only 2 of the 12 cited studies describing the axillary cannulation had more than 100 patients. The authors mentioned that patients with type A dissections are not suitable for any prospective, randomized trials, and the number of the patients of each center is rather small [1].
Our group previously published two articles of 104 patients and 181 patients, respectively, who were operated on due to aortic pathologies with ACP maintained by upper brachial artery cannulation [2, 3]. The number of patients with type A dissections in these studies were 64 and 112, respectively. Therefore, we believe that brachial cannulation is also a major cannulation site for ACP. We are also planning to publish a new study of 132 patients who were operated on with brachial artery cannulation in the near future.
Accepting better neurologic outcome of axillary cannulation is an advantage; the authors assumed malperfusion or dissections of the arch arteries as a drawback to the axillary cannulation. However, deep hypothermia with femoral cannulation also carries the risk of malperfusion, particularly in cases with type A dissections [1]. Besides, in our experience we did not encounter signs of malperfusion in any patient, and brachial artery cannulation is often free from the risk of injury of the arteries of the arch.
The authors mentioned that hypothermic circulatory arrest with femoral cannulation was reported to be safe in a period of 20 to 30 minutes, although no true cutoff point could be defined [1]. However, in our experience, the mean period of low-flow ACP required for arch repair is often more than 30 minutes [2, 3]. This situation seems to be the main endpoint of femoral cannulation. Hence, we believe that the question should be where to insert arterial cannula for ACP instead of comparing axillary artery cannulation and femoral artery cannulation in aortic surgery.
Brachial cannulation has excellent neurologic outcome, provides better surgical exposure, and it is less time consuming [2, 3]. In the light of the previously mentioned information, we believe that brachial artery cannulation is the best for ACP in aortic arch surgery.
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demir O, Saritas A, Küçüker S, Özatik MA, Sener E. Aortic arch repair with right brachial artery perfusion Ann Thorac Surg 2002;73:1837-1842.demir O. Arch repair with unilateral antegrade cerebral perfusion Eur J Cardiothorac Surg 2005;27:638-643.Related Article
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  H. Gulbins Reply Ann. Thorac. Surg., September 1, 2008; 86(3): 1058 - 1058. [Full Text] [PDF]
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