Right Axillary Artery Cannulation and Selective Antegrade Cerebral Perfusion for Surgery of the Ascending Aorta: Initial Experience in a Low-Volume Center

Special Article - Aortic Surgery

Austin J Surg. 2019; 6(11): 1187.

Right Axillary Artery Cannulation and Selective Antegrade Cerebral Perfusion for Surgery of the Ascending Aorta: Initial Experience in a Low-Volume Center

Jacobzon E*, Kholod I, Tager S, Fink D, Merin O and Silberman S

Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, Hebrew University of Jerusalem Medical School, Israel

*Corresponding author: Jacobzon E, Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem, Israel

Received: April 05, 2019; Accepted: May 06, 2019; Published: May 13, 2019

Abstract

Background: Arterial access for cardiopulmonary bypass in proximal aorta surgery is usually performed via the femoral, subclavian, or innominate arteries. We present our initial experience with axillary cannulation performed via the deltopectoral groove, with selective antegrade cerebral perfusion.

Methods: Included are 10 consecutive patients who underwent replacement of the ascending aorta with or without hemi arch: Type A dissection in 4, aortic aneurysm in 6. Right axillary artery is exposed with a deltopectoral groove incision. After division of the pectoralis minor and avoidance of the brachial plexus, an 8-mm graft is sewn end-to-side to the axillary artery and cannulated with a 22F Arterial cannula. Cardiopulmonary bypass is attained via right axillary artery and right atrium. After systemic cooling, the innominate artery is clamped and selective antegrade cerebral perfusion initiated at a flow of 10cc/kg/minute, with perfusion pressure around 60 mm/hg. Once the distal anastomosis of the ascending aorta graft is complete, the arterial clamp is removed from the innominate artery and systemic perfusion is renewed.

Results: Average systemic ischemic time was 36 minutes (range 24-60). Mean bypass time was 176 minutes (range 98-335). All patients made a noneventful recovery, with no incidence of strokes.

Conclusion: Arterial access using the right axillary artery via the right deltopectoral groove is simple and convenient. This artery is seldom involved in the disease process, and is reliably accessible, thus overcoming some of the major pitfalls of other venues. We have adopted this route as our preferred method for arterial cannulation for ascending aortic surgery.

Keywords: Axillary artery cannulation; Ascending aortic surgery; Cardiopulmonary bypass; Cerebral perfusion

Abreviations

CPB: Cardiopulmonary Bypass; DHCA: Deep Hypothermic Circulatory Arrest; MHCA: Moderate Hypothermic Circulatory Arrest; SACP: Selective Antegrade Cerebral Perfusion

Introduction

Surgery of the ascending aorta and aortic arch requires connection to Cardiopulmonary Bypass (CPB). In routine open-heart surgery, arterial access is most often attained via the distal ascending aorta. In cases in which the ascending aorta or arch are involved in the disease process, and particularly in cases of aortic dissection, there are a number of alternate sites for arterial access: the femoral artery, the innominate artery, the subclavian artery, and the axillary artery. When choosing between these options, we need to take into account the major causes of neurologic complications after proximal aortic surgery, which are embolic strokes and temporary neurologic dysfunction, usually due to global ischemia [1].

The right axillary artery is the distal continuation of the subclavian artery. It is easily accessible via an incision in the deltopectoral groove, far from any skeletal structure. It is rarely involved in the dissection process, which makes it an ideal cannulation site for surgery of the aorta. This approach also facilitates arterial access in complex cases such as re-operations. This technique has been previously described by Halkos et al. [2].

Axillary artery cannulation with Selective Antegrade Cerebral Perfusion (SACP) has become the standard of care for operations of the ascending aorta and the aortic arch in many leading centers worldwide. It enables continuous antegrade flow during cardiopulmonary bypass and uninterrupted SACP during systemic circulatory arrest. We have adopted this technique and during the past year have employed it in ten consecutive cases with excellent results. In this manuscript, we describe the technique and present our initial experience.

Materials and Methods

Included are 10 consecutive patients who underwent replacement of the ascending aorta with or without hemi arch replacement. Aortic pathology included: Type A dissection in 4, aortic aneurysm in 6.

Surgical technique:

The right axillary artery is exposed via a deltopectoral groove incision (Figure 1). The pectoralis minor muscle is divided taking care to avoid the brachial plexus, and the axillary artery is exposed. After administration of heparin, the artery is clamped with a side-biting clamp and an 8-mm graft is sewn end-to-side to the axillary artery and then cannulated with a 22F arterial cannula (Figures 2a, 2b). Cardiopulmonary bypass is attained via right axillary artery and right atrium. After systemic cooling, the innominate artery is clamped proximally to enable selective antegrade cerebral perfusion initiated at a flow of 10cc/kg/minute, maintaining a perfusion pressure around 60 mm/hg [2,3]. Cerebral oxygen saturation is used to monitor brain perfusion. Replacement of the ascending aorta is performed in the usual fashion, and once the distal anastomosis is complete, the arterial clamp is removed from the innominate artery and systemic perfusion is renewed.