HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Selami Dogan Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Koray, A.K. Articles by Dogan, S. Search for Related Content PubMed PubMed Citation Articles by Koray, A.K. Articles by Dogan, S. Related Collections Related Article

J Thorac Cardiovasc Surg 2007;133:1392
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Carotid artery cannulation in aortic surgery

Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany

To the Editor:

We read with great interest the article from Dr Urbanski and colleagues¹ describing the results of carotid artery cannulation in aortic surgery. We congratulate them for their success and outstanding effort in one of the most challenging issues in cardiac surgery. However, we have some concerns about the routine cannulation of the left carotid artery for both systemic and antegrade cerebral perfusion (ACP) in aortic surgery.

Data have accumulated that the major cause of cerebral insults after repair of aortic arch or ascending aortic aneurysms is cerebral embolization rather than inadequate cerebral protection, unless the operation is very prolonged. For this reason, selection of the arterial cannulation site for cardiopulmonary bypass is one of the most critical steps during these complex procedures. Ascending aortic, femoral, and axillary arteries are commonly preferred cannulation sites for systemic and/or cerebral perfusion. Dr Urbanski and colleagues¹ claimed that carotid artery cannulation prevents interruption of the cerebral blood flow during placement of the perfusion cannulas in the supra-aortic vessels and the risk of cerebrovascular events as a result of air embolism or the consequent dislodgment of atherosclerotic debris. Also, it avoids the manipulation of the arch arteries for perfusion cannula placement for ACP. On the other hand, in the cardiovascular system, carotid arteries are one of the most vulnerable sites for systemic atherosclerosis. Patients indicated for elective repair of ascending aortic and arch repair usually have multiple risk factors for atherosclerosis and multiple comorbidities like coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD). Dr Urbanski and colleagues reported 85% hypertension, 35% CAD, 16% COPD, and 5% previous neurologic events in their patient population. It has been stated that a significant number of patients undergoing surgical repair for degenerative aneurysm of the descending thoracic and thoracoabdominal aorta has hemodynamically important carotid and coronary artery disease.² Atherosclerotic carotid artery disease, either hemodynamically significant or not, is fairly common in this patient population. In our opinion, carotid artery manipulation for anastomosing a graft to the artery itself and the turbulence secondary to the arterial flow directed to the carotid system further increase the risk for cerebral embolization in these patients. Additionally, carotid artery cannulation for antegrade cerebral protection eliminates the vertebral artery, which is an important collateral for cerebral perfusion.

On the other hand, axillary arteries are relatively resistant to the atherosclerotic process. It has been shown that the right axillary artery cannulation by either direct or side graft technique is an easy and effective technique for both systemic and ACP in aortic surgery.³ Brachial plexus injury, dissection, arm ischemia, compartment syndrome, and local wound complications have been reported to develop after axillary artery cannulation.^3,4 However, we believe that technical problems and complications of axillary cannulation are obviously less considerable, compared with the carotid artery cannulation. Overall, we believe that right axillary artery cannulation is superior to carotid artery cannulation in aortic surgery.

References

1. Urbanski PP, Lenos A, Lindemann Y, Weigang E, Zacher M, Diegeler A. Carotid artery cannulation in aortic surgery. J Thorac Cardiovasc Surg 2006;132:1398-1403.[Abstract/Free Full Text]
   
2. Kieffer E, Chiche L, Baron JF, Godet G, Koskas F, Bahnini A. Coronary and carotid artery disease in patients with degenerative aneurysm of the descending thoracic or thoracoabdominal aorta: prevalence and impact on operative mortality. Ann Vasc Surg 2002;16:679-684.[Medline]
   
3. Strauch JT, Spielvogel D, Lauten A, Lansman SL, McMurtry K, Bodian CA, et al. Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement. Ann Thorac Surg 2004;78:103-108.[Abstract/Free Full Text]
   
4. Budde JM, Serna Jr DL, Osborne SC, Steele MA, Chen EP. Axillary cannulation for proximal aortic surgery is as safe in the emergent setting as in elective cases. Ann Thorac Surg 2006;82:2154-2159.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Selami Dogan Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Koray, A.K. Articles by Dogan, S. Search for Related Content PubMed PubMed Citation Articles by Koray, A.K. Articles by Dogan, S. Related Collections Related Article