Asian Cardiovasc Thorac Ann 2007;15:348-350
© 2007 Asia Publishing EXchange Ltd
Innominate Artery Cannulation for Aortic Surgery
Kuan-Ming Chiu, MD,
Shao-Jung Li, MD,
Tzu-Yu Lin, MD1,
Chih-Yang Chan, MD,
Shu-Hsun Chu, MD
Department of Cardiovascular Surgery
1 Department of Anesthesiology, Cardiovascular Center, Far-Eastern Memorial Hospital, Pan-Chiao, Taiwan
For reprint information contact: Chih-Yang Chan, MD, Tel: 886 2 8966 7000 Ext. 1618, Fax: 886 2 7738 6057, Email: chanchihyang{at}mail.femh.org.tw, Department of Cardiovascular Surgery, Cardiovascular Center, Far-Eastern Memorial Hospital, 13F, 21, Section 2, Nan-Ya South Road, Pan-Chiao, Taipei County 220, Taiwan.
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ABSTRACT
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When disease involving the ascending aorta or aortic arch precludes ascending aortic cannulation, axillary artery cannulation is used for cardiopulmonary bypass. An additional incision and the relatively small caliber of the axillary artery are the drawbacks of this approach. Innominate artery cannulation using the same sternotomy wound is a simple and effective alternative.
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INTRODUCTION
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The ascending aorta is the usual site of arterial inflow for cardiopulmonary bypass (CPB). When disease involves the ascending aorta or aortic arch, ascending aortic cannulation is not feasible. For type A acute aortic dissection, femoral artery cannulation may be an alternative, but it has many drawbacks. Femoral artery size in women can limit cannula size. Atherosclerosis of the descending aorta and iliac artery might cause cerebral embolization. Hypoperfusion is also a major concern. Thus, axillary artery cannulation was introduced.1–4 The most convincing benefit of axillary artery cannulation is cerebral protection because selective antegrade cerebral perfusion can be achieved simply by clamping the innominate artery.5 Some limitations remain, particularly potential brachial plexus injury and limb ischemia.6 The size of the axillary artery usually limits the size of the cannula as well as bypass flow, and an additional wound is required. During selective antegrade cerebral perfusion, there is no easy way to monitor perfusion pressure. Thus, innominate artery cannulation has been considered.7
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TECHNIQUE
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The patient is placed in the supine position and draped with exposure of both sides of the groin and the right subclavian area. A midline sternotomy is performed, the pericardium is incised, and the pathology is examined. The innominate artery is carefully inspected and gently palpated to identify any significant atherosclerotic plaques. Prior to this, systolic blood pressure is lowered to 90 mm Hg with a vasodilator to facilitate palpation of atherosclerosis in the entire ascending aorta, arch, and arch vessels. The innominate vein is mobilized upward or downward to expose the innominate artery. In patients with obvious atherosclerosis or palpable plaques, this approach must be abandoned. According to the size of the innominate artery, a 22F or 24F wire-reinforced flexible short-tipped cannula is used. Double pursestring sutures are applied to the innominate artery as for routine aortic cannulation. Direct cannulation and fixation with snared tourniquets is undertaken. For the initial cooling and final warming processes, the cannula tip is oriented toward the aortic arch (Figure 1
). This allows higher flow and less resistance to CPB. During systemic circulatory arrest and selective antegrade cerebral perfusion, the cannula tip is turned gently toward the head, and a vascular clamp is applied proximal to the cannula (Figure 2). The selective perfusion flow can be adjusted by right radial artery pressure during the entire process.
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DISCUSSION
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From December 2002 to June 2004, 12 patients were operated on in our hospital using this technique. Their diagnoses and surgical procedures are given in Table 1. Nine patients had intraoperative direct ultrasound scanning to exclude atherosclerosis in the innominate artery. In all cases, adequate CPB flows of 2.4 L·m–2·min–1 were achieved. There was no difference between right and left radial arterial pressures during the cooling or rewarming phases. The cannula in the innominate artery and its tip direction did not cause any significant difference in perfusion pressure. All patients survived the operation, and none had a cerebrovascular accident. No postoperative complications related to innominate artery cannulation were noted. All patients regained full consciousness soon after the operation, without any noticeable neurological sequelae. Two patients died in the hospital of complications unrelated to innominate artery cannulation.
There is increasing evidence that femoral artery cannulation results in a higher incidence of cerebral thromboembolism.8 In the last decade, axillary artery cannulation has become routine for surgery involving the ascending aorta and aortic arch. However, the requirement of an additional wound, interruption of right upper extremity perfusion, and loss of monitoring during cerebral perfusion remain concerns. Potential brachial plexus injuries and the small diameter of the axillary artery might prolong the course of CPB and result in additional complications. Direct cannulation could cause trauma or dissection of the axillary artery. Sabik and colleagues6 reported that cannulation with a side graft was associated with less morbidity than direct cannulation. Compared to axillary artery cannulation, innominate artery cannulation carries some benefits. No additional wound is needed, and the same technique and size of cannula as for ascending aortic cannulation are used. The cannula tip can be oriented as needed. Cerebral perfusion pressure can be monitored continuously with a right radial arterial line.
Innominate artery cannulation is indicated for aortic root or arch surgery when the pathology precludes the usual approach for CPB. Ascending aortic surgery or arch reconstruction involving open distal anastomosis or circulatory arrest are other indications. The potential for cerebral embolism still remains, therefore, the innominate artery should be free of disease. Atherosclerosis of the arch vessels usually occurs over the curvature of the aortic arch and the origins of the arch vessels. If there is any evidence of atherosclerosis in the innominate artery, this technique should not be applied. Preoperative non-contrast-enhanced computed tomography usually confirms this. Gentle palpation of the ascending aorta, aortic arch, and arch vessels also provides some information. Intraoperative ultrasound scanning is recommended to identify additional contraindications, such as muddy atherosclerosis, which might not be detected by other modalities. When innominate artery cannulation is indicated, care must be taken during the change of tip direction and cross clamping of the origin of the innominate artery for selective antegrade cerebral perfusion. Gentle handling and transient flow reduction or cessation will ensure the safety of this procedure. By reducing the duration of hypothermic circulatory arrest, the simple technique of innominate artery cannulation with selective cerebral perfusion might be the optimal approach for averting adverse outcomes, reducing complications, and shortening hospital stay after aortic arch repair.
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REFERENCES
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- Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885–91.[Abstract]
- Sinclair MC, Singer RL, Manley NJ, Montesano RM. Cannulation of the axillary artery for cardiopulmonary bypass: safeguards and pitfalls. Ann Thorac Surg 2003;75:931–4.[Abstract/Free Full Text]
- Schachner T, Vertacnik K, Laufer G, Bonatti J. Axillary artery cannulation in surgery of the ascending aorta and the aortic arch. Eur J Cardiothorac Surg 2002;22:445–7.[Abstract/Free Full Text]
- Yavuz S, Goncu MT, Turk T. Axillary artery cannulation for arterial inflow in patients with acute dissection of the ascending aorta. Eur J Cardiothorac Surg 2002;22:313–5.[Abstract/Free Full Text]
- Strauch JT, Spielvogel D, Lauten A, Galla JD, Lansman SL, McMurtry K, et al. Technical advances in total aortic arch replacement. Ann Thorac Surg 2004;77:581–90.[Abstract/Free Full Text]
- Sabik JF, Nemeh H, Lytle BW, Blackstone EH, Gillinov AM, Rajeswaran J, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004;77:1315–20.[Abstract/Free Full Text]
- Banbury MK, Cosgrove DM 3rd. Arterial cannulation of the innominate artery. Ann Thorac Surg 2000;69:957.[Abstract/Free Full Text]
- Schachner T, Laufer G, Vertacnik K, Bonaros N, Nagiller J, Bonatti J. Is the axillary artery a suitable cannulation site in aortic surgery? J Cardiovasc Surg (Torino) 2004;45:15–9.[Medline]
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ABSTRACT
INTRODUCTION
