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ORIGINAL CONTRIBUTIONS |
Department of Cardiovascular Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
For reprint information contact: Kazuhiro Kurisu, MD Tel: 81 93 541 1831 Fax: 81 93 533 8693 Email: byou-iryou-cvs{at}mail2.city.kitakyushu.jp, Department of Cardiovascular Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu 802-0077, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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PATIENTS AND METHODS |
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. There were 9 men and 3 women. Their ages ranged from 43 to 76 years with a mean of 61.3 years. Body weight ranged from 36 to 84 kg with a mean of 61.7 kg. Six patients were operated on for atherosclerotic aneurysm, 3 for acute aortic dissection, and 3 for chronic aortic dissection. Aneurysm repair was performed through a standard median sternotomy in 4 patients, hemi-clamshell incision (L-incision)17 in 6, and the combination of a full median sternotomy and left thoracotomy in 2. Total arch replacement was undertaken in 8 patients, hemiarch replacement in 1, and ascending aorta replacement in 3. Concomitant procedures included coronary artery bypass grafting in 3 patients and aortic root replacement in 2 who underwent valved-conduit replacement combined with coronary artery re-implantation using the button technique. Intraoperative epiaortic echo imaging was routinely performed to evaluate atherosclerotic plaque inside the aorta, especially in patients with a non-dissecting aneurysm. Among 6 patients with an atherosclerotic aneurysm, cannulation of the ascending aorta was judged to be applicable in 2, and one was suitable for aortic crossclamping.
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). The pectoralis major muscle was divided along the direction of its fibers, and the pectoralis minor muscle was divided or retracted laterally. The axillary artery, being easily identified by palpation, was mobilized from the surrounding tissue. An appropriate segment of the artery was excluded by applying bulldog clamps without systemic heparinization, and a longitudinal arteriotomy was made. An 8 mm Hemashield Gold vascular graft (Meadox Medicals, Inc., Oakland, NJ, USA) was sewn to the axillary artery in an end-to-side fashion using 5/0 polypropylene sutures. After removing the bulldog clamps, the graft was clamped as close as possible to the anastomosis (Figure 2).
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The umbilical tapes were tightened on the innominate and left subclavian arteries under systemic hypothermia. After opening the aorta, backflow from the left carotid artery into the aortic arch was confirmed. A 12F balloon-tipped cannula (Sumitomo Bakelite Co. Ltd., Tokyo, Japan) was inserted into the left carotid artery from inside the aorta, and antegrade selective cerebral perfusion was established. As only one pump was used for arterial perfusion, the flow rate of the selective cerebral perfusion was not adjusted. However, the perfusion pressure in the brain was monitored through the right radial artery and controlled at 40–70 mm Hg by regulating the arterial perfusion flow. Retrograde perfusion from the unilateral femoral artery was used only in patients at risk of hypoperfusion related to aortic dissection and those amenable to descending aortic clamping during total arch replacement. Bilateral axillary arterial perfusion was continued after reconstruction of the arch vessels until termination of CPB.
Cardiac arrest was achieved by either aortic root infusion or direct antegrade selective administration of cold crystalloid cardioplegia. The technique of total arch replacement, the "proximal-first" technique, has been described in detail previously and is briefly presented herein.17 The ascending aorta was anastomosed to a Hemashield Gold vascular graft with 4 branches (Meadox Medicals, Inc., Oakland, NJ, USA). Reconstruction of the arch vessels was performed at the left subclavian, left carotid, and innominate artery in turn, and the snare was released. Open distal anastomosis was accomplished using a modified elephant-trunk technique. Anastomosis between the proximal and distal grafts completed the arch reconstruction. After cessation of CPB, the grafts anastomosed to the axillary arteries were clamped, cut several millimeters above the anastomosis, and doubly oversewn with 5/0 polypropylene sutures. The incisions were closed later in layers (Figure 1
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The patients were followed-up until May 2004 by direct contact with them and/or their physicians. The follow-up was 100% complete. The mean duration of follow-up was 15.8 months (range, 3–26 months).
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RESULTS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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). There were no early or late deaths. No patient developed a permanent neurologic deficit. Transient neurologic dysfunction, including postoperative confusion, delirium, or obtundation, did not occur in any patient. The duration of postoperative mechanical ventilation ranged from 12 to 104 h (mean, 37 ± 25 h). Postoperative coronary angiography revealed satisfactory flow in all 5 coronary artery bypass grafts in 3 patients. Re-exploration for bleeding and temporary hemodialysis for acute renal failure was necessary in one patient each. One patient suffered an arch graft infection and was salvaged by aggressive surgical disinfection. Another patient with acute respiratory distress syndrome required prolonged mechanical ventilatory support. All 12 patients were alive and doing well at 3 to 26 months postoperatively.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Recently, a few reports emphasized the importance of the flow characteristics of the arterial cannula.14,15 A high-velocity jet from the arterial cannula has been implicated in the generation of free debris from the aortic intima. The multiple-perfusion method might lessen the risk of stroke by decreasing the flow velocity at each inflow site, thus preventing the detachment of emboli. We are confident that bilateral axillary arterial perfusion is superior to unilateral perfusion from the standpoint of such flow characteristics.
The conventional approach to antegrade selective cerebral perfusion is by direct cannulation of the innominate and left carotid arteries.18,19 This technique is simple and time-saving; however, it must be initiated by systemic perfusion with a cannula in the ascending aorta or femoral artery. This might lead to atheroembolism derived from the diseased aorta, as mentioned above. In this series, we were able to perform ascending aortic cannulation in only 2 of 6 patients with an atherosclerotic aneurysm. Hence, bilateral axillary arterial cannulation is likely to be more reliable than the conventional approach.
Two techniques of axillary arterial cannulation have been described: direct, and through a graft.3–12 Direct cannulation always carries some risk of plaque detachment and arterial dissection because of the hard material of the cannula. We prefer cannulation into a graft because this approach has several advantages. Interposed grafts prevent unexpected ischemic events due to inadequate perfusion of the distal artery.8,9 The perfusion line from the CPB circuit can be freely placed because the graft is very flexible, whereas insertion of a cannula has to be carefully performed in direct cannulation. Furthermore, a peripheral arterial monitor, usually through the right radial artery, is acceptable even in CPB with selective cerebral perfusion when an interposition of graft is employed.
Most surgeons are concerned about the troublesome and time-consuming nature of this approach, and about potential bleeding from the anastomotic site. The right axillary, left axillary, and unilateral femoral arteries can be exposed simultaneously and connected to the grafts in thirty minutes by 3 surgeons working together, and the technical difficulty is gradually overcome by experience. The anastomosis is performed without systemic heparinization, and we did not encounter any hemorrhagic complications in this series. One of the unique aspects of our strategy is the creation of inflow without intravenous administration of heparin. The risk of thromboembolism actually exists, but we have routinely applied this method for more than 10 years, employing femoral arterial cannulation. To minimize contact between the blood and the graft, the graft is clamped as closely as possible to the suture line. We flush out with blood and confirm the absence of any clots inside the graft immediately before connecting to the arterial line for CPB. We have not experienced any case of thromboembolism related to this procedure.
Cerebral blood flow was not measured by transcranial Doppler echo or other techniques; therefore, the precise effect of left axillary arterial perfusion on brain protection is not fully understood. The population was considered too small to compare clinical outcomes with those of other techniques, and further study is necessary. Nevertheless, it was concluded that brain protection during ascending aorta and aortic arch exclusion was achieved by this strategy based on multiple-perfusion through the bilateral axillary arteries. These encouraging preliminary results have led us to use bilateral axillary arterial perfusion routinely as an alternative approach for ascending aorta and arch replacement.
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This article has been cited by other articles:
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  S. Yamashiro, Y. Kuniyoshi, K. Arakaki, H. Inafuku, Y. Morishima, and Y. Kise Aortic Replacement via Median Sternotomy with Left Anterolateral Thoracotomy Asian Cardiovasc Thorac Ann, August 1, 2009; 17(4): 373 - 377. [Abstract] [Full Text] [PDF]
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 S. Morita, M. Yasaka, K. Yasumori, Y. Oishi, T. Takaseya, H. Sonoda, and T. Kawara Transcranial Doppler Study to Assess Intracranial Arterial Communication Before Aortic Arch Operation Ann. Thorac. Surg., August 1, 2008; 86(2): 448 - 451. [Abstract] [Full Text] [PDF]
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 A. Mazzola, R. Gregorini, G. DeCurtis, and M. Ciocca Bilateral axillary artery inflow in the treatment of a rare case of pseudocoartaction of the aortic arch Interactive CardioVascular and Thoracic Surgery, October 1, 2007; 6(5): 652 - 653. [Abstract] [Full Text] [PDF]
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H. Gulbins, A. Pritisanac, and J. Ennker Axillary Versus Femoral Cannulation for Aortic Surgery: Enough Evidence for a General Recommendation? Ann. Thorac. Surg., March 1, 2007; 83(3): 1219 - 1224. [Abstract] [Full Text] [PDF]
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