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J Thorac Cardiovasc Surg 1999;118:1153-1154
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Axillary cannulation: First choice for extra-aortic cannulation and brain protection

New England Heart Institute, Catholic Medical Center
Manchester, NH 03102

To the Editor:

We read with interest the article by Neri and colleagues ¹ about axillary cannulation for type A dissection. They relate a lateral approach, preferentially left, with direct cannulation with excellent results: there were no strokes and no local complications from the cannulation site in 22 patients with type A aortic dissection.

This is the first publication in which direct cannulation of the lateral segment of the artery is used without injury to the artery or the surrounding nerve roots, at least in the initial follow-up. Our experience with axillary cannulation for severe aortic atherosclerosis was recently published, ² and we differ in opinion with the authors in a few points.

First, we prefer a more medial approach to cannulate the axillary artery, thus avoiding the surrounding brachial plexus roots. Second, use of a graft interposition technique allows us to monitor brain perfusion during circulatory arrest through the same graft by reading the ipsilateral right radial artery pressure. To that effect we caution that monitoring of the systemic pressure during total perfusion should be from a contralateral or proximal site from the axillary cannulation site since the ipsilateral radial line usually will read a higher pressure from the significant flow. This is with the interposition technique; obviously, direct cannulation will probably give the opposite results since the distal artery is likely hypoperfused from obstruction of the distal axillary artery itself by the cannula.

Last, the others favor a left axillary approach. Through our experience in more than 80 cases of axillary cannulation, particularly in cases of type A dissection or the need for elective cerebral protection, we favor the right side. Contrary to their opinion, we believe the right-sided approach anatomically allows a very efficient means for cerebral protection since no additional cannulation is needed and the perfusion is simply lowered to the calculated rate. ² Brain pressure monitoring during circulatory arrest time is realized through the right radial line. We agree with Neri and colleagues to avoid manipulation of the common carotid and the innominate ostia. These are never clamped at the time of circulatory arrest until they have been visualized directly or have been seen previously through epiaortic echocardiographic reading. ³ The significant flow obtained with excellent retrograde washing effect through the common carotid, innominate, and even left subclavian arteries through the vertebral-basilar system allows excellent washout effect against any embolic debris, particularly in the case of a significantly atherosclerotic aorta or aneurysm.

Our own experience involves 17 patients with type A dissection over a period of 3 years who were treated with perfusion through a graft interposition on the right axillary artery, 16 having cerebral perfusion through the same graft at the time of circulatory arrest. The mean age was 67.7 years and there were 8 women and 9 men. Mean extracorporeal circulation time was 266.2 minutes, with a mean crossclamp time of 80 minutes and a mean circulatory arrest time of 52 minutes. Sixteen of those 17 patients had antegrade cerebral perfusion, and 1 patient (left axillary approach because of pulseless right upper extremity) had retrograde cerebral protection. All had replacement of the ascending aorta, 5 having an aortic valve replacement and 3 having an arch replacement as well. Ten patients were treated on an emergency basis, with 2 being in shock on admission. Results showed 1 operative stroke with no delayed stroke after the operation and 5 deaths. Average length of stay was 28.3 days.

In summary, we congratulate the authors for their excellent results and agree with the targeted site for cannulation in aortic dissection. We still favor the graft interposition technique, which allows easy closure of the artery and makes safe a more medial approach to the artery, thus avoiding the cervical nerve roots. The additional benefit of superior antegrade brain protection, without any additional cannulation, makes us favor the right-sided approach as well.

References

1. Neri E, Massetti M, Capannini G, Carone E, Tucci E, Diciolla F, et al. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999;118:324-9. [Abstract/Free Full Text]
   
2. Baribeau YR, Westbrook BM, Charlesworth DC, Maloney CT. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg 1998;66:33-7. [Abstract/Free Full Text]
   
3. Baribeau YR, Westbrook BM. Intra-operative epicardial echocardiography. In: Izzat MB, Sanderson JE, St John Sutton MG, editors. Echocardiography in adult cardiac surgery, 1st ed. Oxford: Isis Medical Media; 1999. p. 223-9.
   

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This Article 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): Yvon R. Baribeau Benjamin M. Westbrook David C. Charlesworth Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baribeau, Y. R. Articles by Charlesworth, D. C. Search for Related Content PubMed PubMed Citation Articles by Baribeau, Y. R. Articles by Charlesworth, D. C.