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University Hospital Hamburg, Department of Cardiovascular Surgery, Martinistr. 52, Hamburg, 20249 Germany
(Email: helmutgulbins{at}aol.com).
Ta
demir and colleagues [1] write that the question should be: "Which cannulation site should be used in aortic arch repair?" This is an important question; however, our review [2] focused on two cannulation sites with the largest experience worldwide of (1) femoral and (2) axillary–subclavian artery. When starting our review, we expected to find more evidence for a general recommendation of the axillary artery as the cannulation site compared with the femoral artery. But it is the inhomogeneity of populations, study designs, and surgical techniques that makes it very difficult to achieve true evidence by these single-center experiences.
Our review article [2] dealt with the femoral artery as the "classical" cannulation site compared with the axillary or subclavian artery. The background was the increasing "use" of the latter cannulation site in more and more centers due to the possibility of antegrade cerebral perfusion without any changes in the cannulation site. For this purpose, we compared only the studies using these two cannulation sites. With enough patients included to allow for statistical analysis, there exist many other techniques, such as direct cannulation of each supra-aortic vessel, direct aortic cannulation, trans-apical cannulation, bi-femoral cannulation, and others. It would have exceeded the frame of the review article to include all these experiences, especially due to the inhomogeneity of the patient collectives reported.
In our article, we mentioned the risk of malperfusion for both techniques (ie, axillary and femoral) as they were reported in the literature. As we mentioned in our review, antegrade cerebral perfusion can also be established with femoral cannulation, and the body temperature of these patients does need not to be lowered to 18°C. In addition, in our experience, aortic arch repair does not last longer than 30 minutes in most of the patients.
Tademir and colleagues recommend brachial artery cannulation for aortic arch repair, as they reported in their two articles published in 2002 and 2005 [3, 4]. Despite their good results, this technique is not in common use in most centers worldwide. There are several risks using the brachial artery for cannulation because there is no collateral flow to the forearm, and arterial line pressures are supposed to be rather high due to the lumen of the brachial artery. However, their results are very good.
We congratulate Tademir and colleagues for their excellent results with no signs of malperfusion in any patients in their experience; but this is actually a single-center experience, whereas we tried to carry together the published experience of many centers with these two different cannulation sites. In contrast, the letter of Tademir and colleagues [1] underlines the problem of achieving evidence in this field; their studies are also not randomized. Therefore, the question "which cannulation site is to be used in aortic arch repair" cannot be answered by their studies, too.
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demir O, Yilmazkaya B, Gurkahraman S, Yondem OZ. Brachial cannulation instead of axillary and subclavian cannulation (letter) Ann Thorac Surg 2008;86:1057-1058.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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