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Ann Thorac Surg 2006;81:1177-1178
© 2006 The Society of Thoracic Surgeons

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Correspondence

Closed-Chest Transaxillary Venoarterial ECMO

Cattedra di Cardiochirurgia, Università degli Studi di Milano, Policlinico MultiMedica, Via Milanese 300, Milan, 20099 Italy

(Email: mpocar{at}milanocuore.org).

	Introduction

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To the Editor:

We read the article by Dr Navia and associates [1] regarding axillary arterial inflow for extracorporeal membrane oxygenation (ECMO) in adult patients. In view of the preminently technical nature of a "how to do it" article, we would like to add some specific observations. We recently used venoarterial ECMO support using a BioMedicus centrifugal pump (Medtronic, Eden Prairie, MN) with this approach in 2 patients who had cardiogenic shock and respiratory failure develop after extensive acute myocardial infarction that was initially treated with primary or rescue percutaneous coronary intervention, aortic balloon counterpulsation, and mechanical ventilatory support.

In the report by Dr Navia and associates [1] an 8-mm prosthetic vascular graft was secured to the right axillary artery in 4 of 5 patients, whereas 1 patient underwent direct arterial cannulation. The anastomosis seems to be constructed in a near-perpendicular fashion with respect to the artery, as reported by others [2]. We also used this technique in our first patient. However, we observed progressively increasing vascular resistances on the outflow circuit, particularly at flow rates higher than 2.5 L/min, and the patient progressively had severe edema of the right upper extremity develop. Edema gradually resolved after weaning from ECMO support, which was discontinued after 8 days. In view of these observations, we slightly modified the technique in our second patient. The anastomosis between the interposition graft and the axillary artery was constructed in a more oblique fashion at about 45° to favor a more laminar flow across the pump outflow line. No increase in outflow resistances and only mild ipsilateral extremity edema were noticed during ECMO. The left axillary artery rather than the right was cannulated because of a previously placed right subclavian central venous line and a Swan-Ganz catheter inserted through the right internal jugular vein. The patient was supported for 4 days until echocardiography documented post-infarction ventricular septal rupture. Surgical repair of the septal defect was performed on an emergency basis. The patient was weaned from cardiopulmonary bypass and required delayed sternal closure, but ECMO support was discontinued to reduce bleeding complications.

In summary, we totally agree that the axillary artery is an appealing cannulation site for ECMO in adults and that it is preferable to avoid direct cannulation for longer support duration [1, 2]. This approach allows closed-chest and central, near totally antegrade arterial perfusion, and optimal upper body oxygenation. Two patients represent a limited experience, and flow measurements were not available. However, it can be speculated that an obliquely fashioned Y-anastomosis of the vascular prosthetic graft to the axillary artery is likely to determine a less turbulent and unobstructed flow than a 90° T-anastomosis. This may represent an additional pitfall to prevent unnecessarily high pump regimens to maintain adequate circulatory support with centrifugal pumps, and it may avoid upper extremity hyperperfusion and edema.

	Addendum

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After acceptance of the present letter, one further patient underwent uncomplicated ECMO support with the technique described.

	References

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1. Navia JL, Atik FA, Beyer EA, Vega PR. Extracorporeal membrane oxygenation with right axillary artery perfusion Ann Thorac Surg 2005;79:2163-2165.[Abstract/Free Full Text]
2. Moazami N, Moon MR, Lawton JS, Bailey M, Damiano Jr R. Axillary artery cannulation for extracorporeal membrane oxygenator support in adultsan approach to minimize complications. J Thorac Cardiovasc Surg 2003;126:2097-2098.[Free Full Text]

This article has been cited by other articles:

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

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Marco Pocar Andrea Moneta Francesco Donatelli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pocar, M. Articles by Donatelli, F. Search for Related Content PubMed PubMed Citation Articles by Pocar, M. Articles by Donatelli, F. Related Collections Extracorporeal circulation Related Article