Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement

Subclavian Cannulation Improves Outcome of Surgery for Type a Aortic Dissection

Acute type A aortic dissection is a major emergency that continues to cause significant morbidity and mortality. Given the anatomy of the lesion, different circulatory configurations achieved during cardiopulmonary bypass using different arterial inflow sites can influence outcome. Patients who had subclavian artery cannulation were compared with those who had femoral artery cannulation. Forty-nine consecutive patients (mean age, 60 ± 14 years) undergoing emergency surgery for acute type A aortic dissection between 1999 and 2004 were reviewed. Data on presentation, preoperative characteristics, operative details, hospital mortality, and neurological outcome were analyzed. Twenty-nine patients had femoral artery cannulation, and 20 had subclavian artery cannulation. The groups were comparable in terms of preoperative characteristics. The mean follow-up was 29 months. Subclavian artery cannulation conferred significant advantages in respect of hospital death (10% vs. 44%) and neurological impairment. Significantly fewer patients required re-operation following subclavian artery cannulation.

Bilateral Axillary Arterial Perfusion in Surgery on Thoracic Aorta

Bilateral axillary arterial cannulation for selective cerebral perfusion might minimize cerebral embolic complications during surgery on the ascending aorta and aortic arch. From March 2002 through February 2004, bilateral axillary arterial perfusion was applied in 12 consecutive patients (mean age, 61.3 years). Operative procedures were total arch replacement in 8 patients, hemiarch replacement in 1, and ascending aorta replacement in 3. Antegrade selective cerebral perfusion was established through vascular grafts anastomosed to the bilateral axillary arteries and a perfusion catheter placed directly into the left carotid artery. Bilateral axillary arterial perfusion through the grafts was successful in all patients. There were no early or late deaths and no incidence of neurologic deficit. There were no complications related to cannulation of the axillary arteries. Bleeding, temporary renal failure, acute respiratory distress syndrome, and graft infection occurred in one patient each; all recovered from these complications. Bilateral axillary arterial perfusion is feasible and effective for brain protection during surgery on the ascending aorta and aortic arch.

CT Angiography Analysis of Axillary Artery Diameter versus Common Femoral Artery Diameter: Implications for Axillary Approach for Transcatheter Aortic Valve Replacement in Patients with Hostile Aortoiliac Segment and Advanced Lung Disease

Objective. The use of the axillary artery as an access site has lost favor in percutaneous intervention due to the success of these procedures from a radial or brachial alternative. However, these distal access points are unable to safely accommodate anything larger than a 7-French sheath. To date no studies exist describing the size of the axillary artery in relation to the common femoral artery in a patient population. We hypothesized that the axillary artery is of comparable size to the CFA in most patients and less frequently diseased. Methods. We retrospectively reviewed 110 CT scans of the thoracic and abdominal aorta done at our institution to rule out aortic dissection in which the right axillary artery, right CFA, left axillary artery, and left CFA were visualized. Images were then reconstructed using commercially available TeraRecon software and comparative measurements made of the axillary and femoral arteries. Results. In 96 patients with complete data, the mean sizes of the right and left axillary artery were slightly smaller than the left and right CFA. A direct comparison of the sizes of the axillary artery and CFA in the same patient yielded a mean difference of 1.69 mm ± 1.74. In all patients combined, the mean difference between the axillary artery and CFA was 1.88 mm on the right and 1.68 mm on the left. In 19 patients (19.8%), the axillary artery was of the same caliber as the associated CFA. In 8 of 96 patients (8.3%), the axillary artery was larger compared to the CFA. Conclusions. Although typically smaller, the axillary artery is often of comparable size to the CFA, significantly less frequently calcified or diseased, and in almost all observed cases large enough to accommodate a sheath with up to 18 French.

Axillary Artery Cannulation in Acute Aortic Dissection: A Word of Caution

Arterial cannulation into the right axillary artery is a commonly adopted perfusion strategy in the treatment of acute aortic dissection. Here we describe our experience of accidentally cannulating the axillary artery in a case of acute aortic dissection with an aberrant right subclavian artery, which was missed preoperatively because its proximal segment was malperfused by the dissection and thereby not enhanced. The rapid hemodynamics collapse at the start of the bypass was reversed by prompt switching to femoral perfusion. Postoperative follow-up computed tomographic angiography revealed a well-perfused right aberrant subclavian artery. Surgeons should be aware of an aortic arch anomaly whenever performing an axillary artery cannulation.

Open Seldinger-Guided Femoral Artery Cannulation Technique for Thoracic Aortic Surgery

BACKGROUND

Debate regarding the optimal cannulation site for aortic surgery continues. We report our recent experience with a simple and rapid open Seldinger-guided technique for femoral cannulation. Aside from speed and simplicity (no need for arterial incision or suture closure), this technique has the added benefit that the distal limb continues to be perfused, as no arterial snare is required.

METHODS

We recently began routinely utilizing an open Seldinger-guided technique for femoral artery cannulation. The artery is exposed surgically but cannulated by guidewire inside a pursestring without arterial incision. The pursestring is simply tied when decannulation is performed. We report our experience with the routine application of this technique from August 2011 to April 2015.

RESULTS

We reviewed the outcome of 337 consecutive peripheral arterial cannulations performed for thoracic aortic surgery (303 femoral, 34 axillary) using the open Seldinger technique. Within the femoral cannulation group, the hospital survival rate was 97% (295 of 303). The survival rate for elective operations was 98% (277 of 283), and 90% (18 of 20) for emergent/urgent. Seldinger-guided femoral cannulation was performed for replacement of the ascending/aortic arch in 88% (266 of 303), the descending thoracic aorta in 7% (22 of 303), and the thoracoabdominal aorta in 5% (15 of 303). There were no instances of intraoperative malperfusion phenomena, arterial dissection, or vascular injury or rupture. No patients had postoperative acute limb ischemia. Local wound complications were observed in 1% of patients (3 of 303). The stroke rate was 1.6% (5 of 303). The same open Seldinger technique was also used without complication in the axillary cannulation group.

CONCLUSIONS

An open Seldinger-guided femoral (or axillary) cannulation technique is quick and easy to perform, with minimal vascular or other complications and extremely low risk of stroke. This technique is recommended for its speed, simplicity, and effectiveness, and for its preservation of distal arterial flow (which is occluded with the traditional arterial incision/arterial snare technique).

Innominate artery cannulation during aortic surgery

During aortic surgery, the cannulation of arteries preserving an antegrade flow in the thoracic aorta [ascending aorta, axillary artery, innominate artery (IA) and carotid artery] has been associated with superior survival and neurological outcomes compared with the cannulation of the femoral artery. However, the ideal site of cannulation for both cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion remains under debate. Here, we present our technique of IA cannulation for CPB and antegrade selective cerebral perfusion during surgery of the thoracic aorta.

Operative Strategies and Outcomes in Type a Aortic Dissection after the Enactment of a Multidisciplinary Aortic Surgery Team

Objective

The purpose of this study was to compare operative strategies and patient outcomes in acute type A aortic dissection (ATAAD) repairs before and after the implementation of a multi-disciplinary aortic surgery team.

Methods

Between May 2005 and July 2014, 101 patients underwent ATAAD repair at our institution. A dedicated multidisciplinary aortic surgery team (experienced aortic surgeon, perfusionists, cardiac anesthesiologists, nurses, and radiologists) was formed in 2010. We retrospectively compared ATAAD repair outcomes in patients before (2005–2009, N = 39) and after (2010–2014, N = 62) implementation of our program. Expected operative mortality was calculated using the International Registry of Acute Aortic Dissection preoperative predictive model.

Results

This study demonstrated a significant reduction in operative mortality after implementation of the aortic surgery program (30.8% vs. 9.7%; P = 0.014). There was also an increase in the complexity of surgical technique and perfusion strategies with fewer postoperative complications related to respiratory (P < 0.0001) and renal failure (P = 0.034). Baseline demographics were similar, and there was no statistically significant difference in International Registry of Acute Aortic Dissection predictive variables between the 2 groups. However, there was a 3.5-fold reduction in the observed-to-expected (O/E) operative mortality ratio. There was a 50% increase in volume with a significant number of patients being admitted directly to our aortic center for ATAAD repair, thus avoiding delay in operation related to transfers from a secondary hospital.

Conclusions

Patient outcomes are improved when the surgical treatment of ATAAD is managed by a high-volume multidisciplinary aortic surgery team.

Central cannulation by Seldinger technique: a reliable method in ascending aorta and aortic arch replacement

Background

Extensive type A aortic dissections that involve peripheral great vessels can complicate the choice of a cannulation site for cardiopulmonary bypass. We started to employ direct cannulation of the true lumen on the concavity of the aortic arch by Seldinger technique and evaluated the efficacy of this access technique as an alternative arterial inflow target in aortic surgery.

Material/Methods

Twenty-four consecutive patients (mean age: 59±14 years) underwent type A aortic dissection repair using selective antegrade cerebral perfusion. Direct aortic cannulation was used in 14 cases, subclavian access in 6 patients, and femoral entry in 4 patients. Perioperative factors were evaluated to identify the reliability and eventual benefits of direct cannulation method at the aortic arch.

Results

There were no operative deaths and cumulative 30-day mortality rate was 25% (6). Permanent neurological deficits were not observed; in 1 patient transient changes occurred (4%). Time to reach circulatory arrest was the shortest in the direct access group, with mean 27±11 (CI: 20.6–33.3) min vs. 43±22 (28.0–78.0) min (p=0.058) and 32±8 (23.6–40.4) min (p=0.34) by femoral cannulation and subclavian entry, respectively. Direct arch cannulation resulted in the best renal function in the first 72 h after surgery and similar characteristics were observed in lactic acid levels.

Conclusions

Ultrasound-guided direct cannulation on the concavity of the aortic arch using a Seldinger technique is a reliable method in dissection repairs. Prompt antegrade perfusion provides not only cerebral but also peripheral organ and tissue protection, which is an advantage in this high-risk group of patients.

Restoration and protection of brachial plexus injury: hot topics in the last decade

Brachial plexus injury is frequently induced by injuries, accidents or birth trauma. Upper limb function may be partially or totally lost after injury, or left permanently disabled. With the development of various medical technologies, different types of interventions are used, but their effectiveness is wide ranging. Many repair methods have phasic characteristics, i.e., repairs are done in different phases. This study explored research progress and hot topic methods for protection after brachial plexus injury, by analyzing 1,797 articles concerning the repair of brachial plexus injuries, published between 2004 and 2013 and indexed by the Science Citation Index database. Results revealed that there are many methods used to repair brachial plexus injury, and their effects are varied. Intervention methods include nerve transfer surgery, electrical stimulation, cell transplantation, neurotrophic factor therapy and drug treatment. Therapeutic methods in this field change according to the hot topic of research.

Direct innominate artery cannulation for selective antegrade cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery

OBJECTIVE

To demonstrate a novel, reproducible, and effective method of direct innominate artery cannulation using a 14 F pediatric venous cannula to establish antegrade cerebral protection (ACP) in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement.

METHODS

We reviewed prospectively gathered data on all patients who had undergone replacement of the ascending aorta or hemiarch with an open distal anastomosis using deep hypothermic circulatory arrest and direct innominate artery cannulation with a 14 F pediatric venous cannula at our institution. After central cannulation and cooling to 25 °C to 28 °C, all patients had ACP initiated by way of a direct innominate cannula placed over a guidewire.

RESULTS

Fifty patients underwent direct innominate artery cannulation with our technique from 2010 to 2012. The operative mortality was 2% (n = 1), and the rates of neurologic morbidity were acceptable and similar to those with other methods of ACP delivery: stroke (2%, n = 1), seizure (0%, n = 0), and delirium (18%, n = 9). The mean operative time was 31 ± 9, 19 ± 5, 100 ± 39, 141 ± 39, and 259 ± 63 minutes for cooling, circulatory arrest, crossclamp, cardiopulmonary bypass, and total operative time, respectively. No local or arterial complications were observed.

CONCLUSIONS

Direct cannulation of the innominate artery using a 14 F pediatric venous cannula is a simple, reproducible, safe, and effective technique for establishing ACP in patients undergoing aortic surgery that requires an open distal anastomosis or hemiarch replacement. This technique avoids the additional time and potential local complications associated with other established methods for delivering ACP, such as axillary cannulation.

Operative techniques in association with arrhythmia surgery in patients with congenital heart disease

Arrhythmia surgery in patients with congenital disease is challenged by the range of anatomic variants, arrhythmia types, and intramyocardial scar location. Experimental and clinical studies have elucidated the mechanisms of arrhythmias for accessory connections, atrial fibrillation, atrial reentry tachycardia, nodal reentry tachycardia, focal or automatic atrial tachycardia, and ventricular tachycardia. The surgical and transcatheter possibilities are numerous, and the congenital heart surgeon should have a comprehensive understanding of all arrhythmia types and potential methods of ablation. The purpose of this article is to introduce resternotomy techniques for safe mediastinal reentry and to review operative techniques of arrhythmia surgery in association with congenital heart disease.

Right axillary and femoral artery perfusion with mild hypothermia for aortic arch replacement

Objectives

Aortic arch replacement is associated with increased mortality and morbidity especially in acute type-A aortic dissection. Although hypothermic circulatory arrest with selective antegrade cerebral perfusion has been widely used because of its excellent cerebral protection, its optimal perfusion characteristics are unknown. The present study investigates clinical results obtained after perfusion method modification and temperature management during cardiopulmonary bypass (CPB).

Methods

Between July 2010 and August 2012, 16 consecutive adult patients (mean age 50.0 yr ± 14.1 yr, range 25 yr to 73 yr, 12 males, 4 females) who presented with acute Stanford type-A aortic dissection underwent aortic arch replacement (total arch, n = 11; hemiarch, n = 5) under mild hypothermia (31.1°C ± 1.5°C) with right axillary and femoral artery perfusion.

Results

The mean CPB time was 201 min ± 53 min, and the mean myocardial ischemic time was 140 min ± 42 min. The mean selective cerebral perfusion time was 80 min ± 16 min, and the mean lower-body circulatory arrest time was 20 min ± 13 min. No patient death occurred within 30 post-operative days. The following details were observed: new post-operative permanent neurologic deficit in 1 patient (6.3%), temporary neurologic deficit in 2 patients (12.5%), acute renal dysfunction (creatinine level > 230 umol/L) in 3 patients (18.8%) and mechanical ventilation > 72 h in 5 patients (31.2%).

Conclusions

Aortic arch replacement for acute type-A aortic dissection under mild hypothermia with right axillary and femoral artery perfusion could be safely performed in the patient cohort.

Efficacy of right axillary artery perfusion for antegrade cerebral perfusion in open total arch repair

OBJECTIVE

Right axillary artery (RAxA) perfusion was introduced for selective antegrade cerebral perfusion in total aortic arch repair to prevent cerebral embolism derived from arterial cannulation. However, the strategic benefits and long-term results regarding the cannulation site remain controversial. We retrospectively compared the outcomes between propensity score-matched patients with and without using RAxA cannulation.

METHODS

Between 2006 and 2012, 260 consecutive patients underwent total arch repair with antegrade cerebral perfusion and moderate hypothermia at a single institution. RAxA cannulation was added in 142 patients (54.6%), and 70 propensity score-matched pairs were obtained.

RESULTS

There were no significant differences in 30-day (2.9% [2 of 70] vs 5.7% [4 of 70]; P = .415 and in-hospital death (5.7% [4 of 70] vs 5.7% [4 of 70]; P = 1.000) between matched pairs. Although there was no significant difference in the occurrence of postoperative stroke (8.6% [6 of 70] vs 8.6% [6 of 70]; P = 1.000), the new rate of new occurrence of postoperative paraparesis was lower in patients with RAxA perfusion (0% [0 of 70] vs 4.3% [3 of 70]; P = .067). With a mean follow-up period of 1057 ± 686 days, the overall 5-year survival was 90.6% and was 89.6% for patients with RAxA perfusion. Thee difference in survival between patients with and without RAxA perfusion was not significant.

CONCLUSIONS

RAxA perfusion is a useful option for total aortic arch repair, and the midterm outcomes were satisfactory. However, RAxA perfusion did not completely prevent stroke in patients with an atherothrombotic aorta.

Overcoming Challenges in the Management of Critical Events During Cardiopulmonary Bypass

Critical events during cardiopulmonary bypass (CPB) can challenge the most experienced perfusionists, anesthesiologists, and surgeons and can potentially lead to devastating outcomes. Much of the challenge of troubleshooting these events requires a key understanding of these situations and a well-defined strategy for early recognition and treatment. Adverse situations may be anticipated prior to going on CPB. Atherosclerosis is pervasive, and a high plaque burden may have implications in surgical technique modification and planning of CPB. Hematologic abnormalities such as cold agglutinins, antithrombin III deficiency, and hemoglobin S have been discussed with emphasis on managing complications arising from their altered pathophysiology. Jehovah’s witness patients require appropriate techniques for cell salvage to minimize blood loss. During initiation of CPB, devastating situations leading to acute hypoperfusion and multiorgan failure may be encountered in patients undergoing surgery for aortic dissection. Massive air emboli during CPB, though rare, necessitate an urgent diagnosis to detect the source and prompt management to contain catastrophic outcomes. Gaseous microemboli remain ubiquitous and continue to be a major concern for neurocognitive impairment despite our best efforts to improve techniques and refine the CPB circuit. During maintenance of CPB, adverse events reflect inability to provide optimal perfusion and can be ascribed to CPB machine malfunction or physiological aberrations. We also discuss critical events that can occur during perfusion and the need to monitor for organ perfusion in altered physiologic states emanating from hemodilution, hypothermia, and acid–base alterations.

Advantages of upper brachial artery cannulation in aortic surgery

BACKGROUND

The best method of cerebral protection during aortic arch surgery remains controversial. However, antegrade cerebral perfusion seems to be the most favorable because of better neurological outcomes. Although there have been many studies on antegrade cerebral perfusion via upper brachial cannulation, there is a lack of studies focusing particularly on local complications, with objective findings. The aim of this study was to investigate the local neurological and vascular complications following upper brachial cannulation.

METHODS AND RESULTS

This study included 44 patients who underwent procedures on the ascending aorta, aortic arch, or descending aorta with upper brachial artery cannulation for cardiopulmonary bypass at OSM Ortadogu Hospital and Cankaya Hospital between January 2009 and April 2012. The mean age of the 32 (72.7%) men and 12 (27.3%) women was 55.2 ± 12.3 years. Doppler analysis of the upper brachial artery was performed in 26 (59%) patients. Mean follow-up time for Doppler analysis was 5.7 ± 2 months. The mean antegrade cerebral perfusion time was 35 ± 16.1 min. The mean degree of hypothermia was 25.1 ± 2.0 . Hospital death occurred in 4 (9.1%) patients, and 2 (4.5%) suffered local neurologic complications. Electromyelography analysis was carried out in the 2 patients who suffered local neurologic symptoms.

CONCLUSIONS

Brachial artery cannulation is technically simple and less time consuming, thus suitable even for emergency cases. With an acceptable risk of local complications, we recommend routine use of upper brachial cannulation for antegrade cerebral perfusion.

A safe and rapid direct true lumen cannulation for acute type A aortic dissection

OBJECTIVE

For the repair of acute type A aortic dissection (AADA), the optimal site of arterial cannulation remains controversial. We herein describe and investigate a technique for direct true lumen cannulation in patients with AADA.

METHODS

Between January 2011 and April 2012, 176 consecutive patients underwent emergency surgery for repair of AADA using the direct true lumen cannulation. Using this method, following temporary circulatory arrest, the dissected ascending aortic wall is incised transversely and the true lumen is identified. An aortic cannula is inserted into the true lumen directly, and the ascending aorta is snared tightly.

RESULTS

The manipulation was performed within 30 s in all patients. There were no technical problems with this method. The mean operative time, cardiopulmonary bypass time, cross-clamp time, and the circulatory arrest time were 241 ± 79, 158 ± 85, 123 ± 97 and 58 ± 39 min, respectively. There were no permanent neurological disorders following surgery. Seven patients (4.0 %) experienced temporary neurological disorders. Twenty-four patients (14 %) died in the hospital from several complications unrelated to technical problems of direct true lumen cannulation.

CONCLUSIONS

Antegrade perfusion can be established safely and easily using the direct true lumen cannulation, which may be a promising standard arterial cannulation technique for the repair of AADA.

Arch replacement using antegrade selective cerebral perfusion for shaggy aorta

Background: Embolic stroke during arch replacement is a serious concern in patients with shaggy aorta.

Objective: To evaluate shaggy aorta in patients who received total aortic arch replacement with antegrade selective cerebral perfusion utilizing axillary perfusion.

Method: Between January 2005 and December 2010, 63 patients underwent preoperative contrast-enhanced computed tomography scanning of the aorta to evaluate atheromatous plaque. We analyzed operative data to investigate which factors were associated with outcomes and survival.

Results: Shaggy aorta was found in 34 (54%) patients. There were 3 (5%) cases in the ascending aorta, 26 (41%) in the aortic arch, and 19 (30%) in the descending aorta. Operative mortality occurred in 1 (2%) patient. Although stroke occurred in 2 (3%) shaggy aorta patients, shaggy aorta was not associated with an increased likelihood of stroke ( p = 0.4951). Survival was significantly lower in patients with shaggy descending aorta ( p = 0.0411) and in patients >75-years old ( p = 0.0200); these traits were identified as independent risk factors for late death ( p = 0.0368 and p = 0.0100, respectively).

Conclusion: We concluded that our perfusion technique protects patients with shaggy aorta against embolism, and that the survival is lower in patients with shaggy descending aorta.

Innominate artery cannulation: an alternative to femoral or axillary cannulation for arterial inflow in proximal aortic surgery

OBJECTIVE

To evaluate the effectiveness of innominate artery cannulation in proximal aortic procedures, including those involving hypothermic circulatory arrest.

METHODS

A total of 68 patients underwent innominate artery cannulation with a side graft during proximal aortic surgery performed by way of a median sternotomy. The indications for surgery were proximal arch aneurysm in 43 patients (63.2%), aortic dissection in 11 patients (16.2%), total arch aneurysm in 10 patients (14.7%), and ascending aortic aneurysm in 4 patients (5.9%). Six patients (8.8%) had undergone previous sternotomy. Hypothermic circulatory arrest with antegrade cerebral perfusion was used in 64 patients (94.1%). Of the 68 patients, 63 (92.6%) received antegrade cerebral perfusion to both cerebral hemispheres. The median antegrade cerebral perfusion time was 20 minutes (range, 15.0-33.0 minutes). Seven patients had periods of circulatory arrest without antegrade cerebral perfusion for a median of 20 minutes (range, 6-33 minutes).

RESULTS

One patient died, for 30-day mortality of 1.5%. Three patients (4.4%) had strokes, two of whom had a partial recovery. Seven patients (10.3%) developed temporary postoperative confusion that resolved successfully in all cases.

CONCLUSIONS

Cannulating the innominate artery for arterial inflow is an alternative technique for proximal aortic surgery procedures. It is especially useful in cases requiring hypothermic circulatory arrest to deliver antegrade cerebral perfusion.

Near-Infrared Spectroscopy-Detected Cerebral Ischemia Resolved by Cannulation of an Axillo-Femoral Graft during Surgical Repair of Type A Aortic Dissection

We report the case of a patient who experienced near-infrared spectroscopy (NIRS)-detected transient regional cerebral desaturation during cardiopulmonary bypass for an operation to replace the aortic arch. Prompt institution of additional flow through an axillo-femoral graft was associated with restoration of regional cerebral saturation. The aortic surgery had no neurologic complications. Promptness in detecting and restoring cerebral perfusion appeared crucial in avoiding prolonged cerebral ischemia and reducing the likelihood of adverse neurologic events.

Comparison of the Outcomes between Axillary and Femoral Artery Cannulation for Acute Type A Aortic Dissection

Background

At present, many surgeons prefer axillary artery cannulation because it facilitates antegrade cerebral perfusion and may diminish the risk of cerebral embolization. However, axillary artery cannulation has not been established as a routine procedure because there is controversy about its clinical advantage.

Materials and Methods

We examined 111 patients diagnosed with acute type A aortic dissection between January 2000 and December 2009. The right axillary artery was cannulated in 58 patients (group A) and the femoral artery was cannulated in 53 (group F). The postoperative outcomes were retrospectively reviewed and compared between the two groups.

Results

There were 46 male and 65 female patients with a mean age of 58.9±13.1 years (range, 26 to 84 years). The extent of aortic replacement in both groups did not differ. There were 8 early deaths (7.2%) and 2 late deaths (1.8%). The mean follow-up duration was 46.0±32.6 months (range, 1 month to 10 years). Transient neurologic dysfunction was observed in 11 patients (19.0%) in group A and 14 patients (26.4%) in group F. A total of 11 patients (9.9%) suffered from a permanent neurologic dysfunction. Early and delayed stroke were observed in 6 patients (10.3%) and 2 patients (3.4%), respectively, in group A as well as 2 patients (3.8%) and 1 patient (1.9%), respectively, in group F. There were no statistical differences in the cannulation-related complications between both groups (3 in group A vs. 0 in group F).

Conclusion

There were no differences in postoperative neurologic outcomes and cannulation-related complications according to the cannulation sites. The cannulation site in an aortic dissection should be carefully chosen on a case-by-case basis. It is important to also pay attention to the possibility of intraoperative malperfusion syndrome occurring and the subsequent need to change the cannulation site.

Midterm results of axilloaxillary cardiopulmonary bypass

BACKGROUND

Total axilloaxillary cardiopulmonary bypass (CPB) is an alternative peripheral cannulation technique that has the advantages of antegrade flow during CPB, monohemispherical brain perfusion in case of circulatory arrest, and achieving excellent decompression of the heart during sternotomy. The results of this strategy, particularly beyond the immediately postoperative period, are not well known.

METHODS

Eleven patients with huge aortic aneurysms (>80 mm) and/or acute-subacute ascending aorta dissections underwent surgery with totally axilloaxillary CPB. Short- and midterm outcomes, including survival and complications relating to axilloaxillary cannulation, were reported.

RESULTS

All attempts at axillary artery cannulation were successful. Ten of the 11 axillary vein cannulation attempts were successful, and the target pump flow was achieved via the axillary vein alone. Postoperatively, clinical examinations revealed no cases of arm ischemia or compartment syndrome. Three patients (27.3%) experienced ipsilateral brachial plexus neuropathy that produced right hand weakness. The neuropathy was transient in 2 patients, and the symptoms resolved completely. Hospital death occurred in 1 (9.1%) of the 11 patients. The mean (±SD) follow-up time was 956 ± 292 days. One of the survivors died on postoperative day 105 from subacute graft infection and sepsis. The right arms of all 9 of the living patients were examined physically and by Doppler ultrasonography. We found a chronic recanalized thrombotic change in the subclavian vein in 1 patient (11.1%), who had no complaints.

CONCLUSIONS

Axilloaxillary CPB is an alternative technique that can be used under certain conditions. Adding axillary venous cannulation to axillary artery cannulation at least does not increase the risk of a procedure that uses the axillary artery alone, either in the early or mid term.

Aortic arch replacement using a trifurcated graft

A critical consideration in the operative strategy for aortic arch replacement, how best to protect the brain while providing surgical access to the cerebral vessels, involves two key aspects: minimizing cerebral ischaemia and preventing cerebral embolization of air and atheromatous debris. We describe a technique, using a trifurcated branched graft, that combines hypothermic circulatory arrest, selective antegrade perfusion and axillary artery cannulation.

Minimally invasive valve surgery with antegrade perfusion strategy is not associated with increased neurologic complications

BACKGROUND

A Society of Thoracic Surgeons' publication recently associated "minimally invasive" approaches with increased neurologic complications; this proposed association was questionable due to imprecise definitions. To critically reevaluate this issue, we reviewed a large minimally invasive valve experience with robust definitions.

METHODS

From November 1995 to January 2007, 3,180 isolated, non-reoperative valve operations were performed; 1,452 (45.7%) were aortic replacements and 1,728 (54.3%) were mitral valve procedures. Surgical approach was standard sternotomy (28%) or minimally invasive technique (72%). Antegrade arterial perfusion was used in 2,646 (83.2%) patients and retrograde perfusion in 534 (16.8%). Aortic clamping was direct in 83.4%, with endoclamp in 16.4% and no clamp in 0.2%. Patients were prospectively followed in a proprietary database and the New York State Cardiac Surgery Reporting System (mandatory, government audited). A neurologic event was defined as a permanent deficit, a transient deficit greater than 24 hours, or a new lesion on cerebral imaging.

RESULTS

Hospital mortality for aortic valve replacement was 4.0% (sternotomy [5.1%] versus minimally invasive [3.4%] p = 0.13); for mitral procedures it was 2.4% (sternotomy [4.8%] versus minimally invasive [1.8%] p = 0.001). Multivariate analysis revealed that age, female gender, renal disease, ejection fraction less than 0.30, chronic obstructive pulmonary disease, and emergent operation were risk factors for mortality. Stroke occurred in 71 patients (2.2%) (sternotomy [2.1%] versus minimally invasive [2.3%] p = 0.82). Multivariate analysis of neurologic events revealed that cerebrovascular disease, emergency procedure, no-clamp, and retrograde perfusion were risk factors. In patients 50 years old or younger (n = 662), retrograde perfusion had no significant impact on neurologic events (1.6% vs 1.1%, p = 0.57).

CONCLUSIONS

A minimally invasive approach with antegrade perfusion does not result in increased neurologic complications. Retrograde perfusion, however, is associated with increased neurologic risk in older patients.

State of the art in neuroprotection during acute type A aortic dissection repair

Temporary (TND) or permanent neurologic dysfunctions (PND) represent the main neurological complications following acute aortic dissection repair. The aim of our experimental and clinical research was the improvement and update of the most common neuroprotective strategies which are in present use.

Hypothermic circulatory arrest (HCA): Cerebral metabolic suppression at the clinically most used temperatures (18-22°C) is less complete than had been assumed previously. If used as a ‘stand-alone’ neuroprotective strategy, cooling to 15-20°C with a jugular SO2 ≥ 95% is needed to provide sufficient metabolic suppression. Regardless of the depth of cooling, the HCA interval should not exceed 25 min. After 40 min of HCA, the incidence of TND and PND increases, after 60 min, the mortality rate increases.

Antegrade selective cerebral perfusion (ASCP): At moderate hypothermia (25-28°C), ASCP should be performed at a pump flow rate of 10ml/kg/min, targeting a cerebral perfusion pressure of 50-60mmHg. Experimental data revealed that these conditions offer an optimal regional blood flow in the cortex (80±27ml/min/100g), the cerebellum (77±32ml/min/100g), the pons (89±5ml/min/100g) and the hippocampus (55±16ml/min/100g) for 25 minutes. If prolonged, does ASCP at 32°C provide the same neuroprotective effect?

Cannulation strategy: Direct axillary artery cannulation ensures the advantage of performing both systemic cooling and ASCP through the same cannula, preventing additional manipulation with the attendant embolic risk. An additional cannulation of the left carotid artery ensures a bi-hemispheric perfusion, with a neurologic outcome of only 6% TND and 1% PND.

Neuromonitoring: Near-infrared spectroscopy and evoked potentials may prove the effectiveness of the neuroprotective strategy used, especially if the trend goes to less radical cooling.

Conclusion: A short interval of HCA (5 min) followed by a more extended period of ASCP (25 min) at moderate hypothermia (28°C), with a pump flow rate of 10ml/kg/min and a cerebral perfusion pressure of 50 mmHg, represents safe conditions for open arch surgery.

Deep hypothermic circulatory arrest: Alternative strategies for cerebral perfusion. A review article

Deep hypothermic circulatory arrest is an essential tool in the surgeon’s armamentarium. There are essentially three strategies to address cerebral ischemia during arrest periods. Early surgical case series pioneered the option of complete anoxia with deep hypothermia. Subsequent innovators introduced the concept of retrograde perfusion of the cerebral vessels through the venous system, and others have advocated the use of selective and non-selective antegrade perfusion of the cerebral arteries. Clinical studies assessing outcomes of the three approaches are compromised by small patient numbers, retrospective design and surgeon bias.

In this review, the authors will briefly discuss the conceptual basis of these strategies and the literature comparing these approaches in terms of key neurologic outcomes. The importance of this topic will emphasize the key role the perfusion community plays in establishing guidelines for best practice in circulatory arrest to go forward with education and research in this area.

Clinical Results of Ascending Aorta and Aortic Arch Replacement under Moderate Hypothermia with Right Brachial and Femoral Artery Perfusion

Background

Selective antegrade perfusion via axillary artery cannulation along with circulatory arrest under deep hypothermia has became a recent trend for performing surgery on the ascending aorta and aortic arch and when direct aortic cannulation is not feasible. The authors of this study tried using moderate hypothermia with right brachial and femoral artery perfusion to complement the pitfalls of single axillary artery cannulation and deep hypothermia.

Materials and Methods

A retrospective analysis was performed on 36 patients who received ascending aorta or aortic arch replacement between July 2005 and May 2010. The adverse outcomes included operative mortality, permanent neurologic dysfunction and temporary neurologic dysfunction.

Results

Of these 36 patients, 32 (88%) were treated as emergencies. The mean age of the patients was 61.9 years (ranging from 29 to 79 years) and there were 19 males and 17 females. The principal diagnoses for the operation were acute type A aortic dissection (31, 86%) and aneurysmal disease without aortic dissection (5, 14%). The performed operations were ascending aorta replacement (9, 25%), ascending aorta and hemiarch replacement (13, 36%), ascending aorta and total arch replacement (13, 36%) and total arch replacement only (1, 3%). The mean cardiopulmonary bypass time was 209.4±85.1 minutes, and the circulatory arrest with selective antegrade perfusion time was 36.1±24.2 minutes. The lowest core temperature was 24±2.1℃. There were five deaths within 30 post-op days (mortality: 13.8%). Two patients (5.5%) had minor neurologic dysfunction and six patients, including three patients who had preoperative cerebral infarction or unconsciousness, had major neurologic dysfunction (16.6%).

Conclusion

When direct aortic cannulation is not feasible for ascending aorta and aortic arch replacement, the right brachial and femoral artery can be used as arterial perfusion routes with the patient under moderate hypothermia. This technique resulted in acceptable outcomes.

Axillary artery cannulation for aortic and complex cardiac surgery

BACKGROUND

Cannulation of the axillary artery for cardiopulmonary bypass (CPB) avoids manipulation of an atherosclerotic, aneurysmal, or dissected ascending aorta. Advantages include: low risk of atheroemboli, low risk of malperfusion in dissections, and facilitates selective antegrade cerebral perfusion (SACP) during hypothermic circulatory arrest (HCA).

METHODS

A single surgeon's seven year experience of axillary cannulation using the side-graft technique in 116 consecutive patients (age 22-87 years) in aortic and cardiac surgery where the ascending aorta was unapproachable. The indication for axillary cannulation was: (i) acute Type A dissection in 22, (ii) elective aortic surgery in 70, (iii) CPB prior to redo sternotomy in five, and (iv) a porcelain aorta in 19. HCA was used in 98 cases and additionally SACP was used in 18 cases.

RESULTS

There were three postoperative deaths, one from multi-system failure, one stroke, and one post discharge from an unknown cause. All 113 other patients were well and discharged home. There were no major complications related to axillary artery use.

CONCLUSION

Axillary artery cannulation is a safe and reliable technique for arterial inflow minimising the risks of atheroembolisation and malperfusion reflected by low morbidity and mortality, and should be the standard in aortic and complex cardiac surgery.