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J Thorac Cardiovasc Surg 2004;128:386-390
© 2004 The American Association for Thoracic Surgery

Cardiopulmonary support and physiology

Axillary artery cannulation for cardiopulmonary bypass reduces cerebral microemboli

^a Division of Cardiothoracic Surgery, Case Western Reserve University/University Hospitals of Cleveland, Cleveland, Ohio, USA

Received for publication August 7, 2003; revisions received November 14, 2003; revisions received January 8, 2004; accepted for publication January 28, 2004.

^* Address for reprints: Alan H. Markowitz, MD, University Hospitals of Cleveland, Cardiothoracic Surgery, 11100 Euclid Ave, Cleveland, OH 44106-5011, USA
alan.markowitz{at}uhhs.com

BACKGROUND: Aortic cannulation for cardiopulmonary bypass (CPB) is linked to cerebral microemboli emanating from the ascending aorta. Aortic calcification or disease requiring replacement precludes aortic cannulation. Clinical experience with axillary artery cannulation led to the hypothesis that axillary cannulation may be cerebroprotective.

METHODS: Five mongrel dogs underwent a median sternotomy and isolation of the right axillary artery. The canine bicarotid brachiocephalic trunk was reconfigured by grafting the origin of the left carotid to the proximal left subclavian artery. Microspheres were injected into the ascending aorta during 4 conditions: before and after reconfiguration, CPB with aortic cannulation, and CPB with axillary cannulation. Brain, kidneys, and skeletal muscle were analyzed for microsphere distribution.

RESULTS: Each animal served as its own control for comparison of aortic and axillary cannulation. No significant differences were documented in microsphere deposition for prereconfiguration and postreconfiguration. In the right middle cerebral artery distribution, 2300 ± 710 microspheres per gram were deposited during aortic cannulation, compared with 540 ± 110 during axillary cannulation (P < .05). In the left middle cerebral artery region, 2030 ± 330 microspheres per gram with aortic cannulation were reduced to 1320 ± 240 with axillary cannulation (P < .05). Axillary cannulation resulted in 73% fewer microspheres in the right brain and 40% fewer microspheres in the left compared with aortic cannulation (P < .05).

CONCLUSIONS: Axillary artery cannulation for CPB is cerebroprotective. Altered blood-flow patterns during axillary cannulation may produce retrograde brachiocephalic artery blood flow and competing intracerebral right-to-left collateral blood flow, deflecting emboli from the ascending aorta and arch toward the descending aorta. Expanded use of axillary artery cannulation during cardiac operations could decrease the incidence of stroke.

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