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J Thorac Cardiovasc Surg 2000;119:1298
© 2000 The American Association for Thoracic Surgery

LETTERS TO THE EDITOR

Notes about axillary cannulation

Istituto di Chirurgia Cardiovascolare, Universitá agli Studi di Siena, Policlinico le Scotte

Viale M. Bracci

53100 Siena, Italy

To the Editor:

We read with interest the comments ^1,2 on our article about axillary cannulation for type A aortic dissection, ³ and we are honored by the attention paid to our work.

Since August 1998, axillary cannulation has been used in 13 more patients with type A aortic dissection in our institution. The axilla has now become our site of choice for arterial perfusion. No brachial plexus injury has been recorded and no lesion of the axillary artery has occurred. These results emphasize that direct cannulation is safe when a lateral approach is used, as well. Moreover, in the past 5 years, we have performed this lateral vascular access in more than 130 axillo-femoral bypass procedures for peripheral disease without local complications.

We fully agree that the graft interposition technique offers important advantages in terms of systemic pressure monitoring and decannulation. However, direct cannulation is more expeditious, an advantage in patients with type A aortic dissection. Furthermore, it is more difficult to evacuate air from the graft than from the cannula, and this may be disadvantageous.

Another point of controversy is that the choice of the left axillary artery, instead of the right, precludes the use of this route for elective cerebral protection. Besides our shared apprehension about manipulating the innominate artery, another major concern remains that of embolization at the beginning of perfusion, which can be avoided if the left axillary artery is used.

To assess this point, we have performed transcranial Doppler monitoring of the bilateral middle cerebral arteries in 6 patients treated for acute type A aortic dissection. Three of them received right axillary cannulation and 3 left axillary cannulation. Although none of the patients had clinically detectable consequences, microembolic signals were detected at the beginning of the perfusion in all patients having right axillary cannulation, whereas no signal was detected in the 3 patients with left axillary cannulation.

We have encountered only one difficulty with axillary artery cannulation that does not occur with femoral artery cannulation. During total aortic arch replacement for type A aortic dissection, at the moment of circulatory arrest, the descending aorta tends to empty. We cannot fill the aorta and the graft retrogradely, as we can with femoral artery cannulation. Therefore, once the anastomosis of the button containing the supra-aortic branches has been completed, we have too much air to evacuate. From this viewpoint, we agree that right axillary artery cannulation provides a theoretical advantage over left axillary artery cannulation by allowing retrograde washing of air bubbles through the common carotid, innominate, and even left subclavian arteries through the vertebral-basilar system.

12/8/106032 doi:10.1067/mtc.2000.106032

References

1. Neri E, Massetti M, Capannini G, Carone E, Tucci E, Diciolla F, et al. Axillary artery cannulation in type A aortic dissection operations. J Thorac Cardiovasc Surg 1999;118:324-9. [Abstract/Free Full Text]
   
2. Gillinov AM, Sabik JF, Lytle BW, Cosgrove DM. Axillary artery cannulation [letter]. J Thorac Cardiovasc Surg 1999;118:1153. [Free Full Text]
   
3. Baribeau YR, Westbrook BM, Charlesworth DC. Axillary cannulation: first choice for extra-aortic cannulation and brain protection [letter]. J Thorac Cardiovasc Surg 1999;118:1153.
   

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