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Internal mammary artery for arterial pressure monitoring after pediatric cardiac operations
Internal Mammary Artery for Arterial Pressure Monitoring After Pediatric Cardiac Operations Mark S. Slaughter, MD, Vibhu R. Kshettry, MD, Philip C. Smith, MD, and John E. Foker, MD, PhD Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis, Minnesota
Establishing and maintaining arterial access in pediatric cardiac operations is a frequent and sometimes frustrating problem. We have modified a procedure commonly used in our research laboratory for arterial pressure monitoring and applied it successfully to the pediatric cardiac surgical patient. The internal mammary artery can provide reliable arterial access in the postoperative period. (Ann Thorac Surg 1993;56:1421-2)
A
n indwelling arterial catheter allows continuous arterial blood pressure monitoring and access for routine laboratory tests and measurement of arterial blood gas values. In infants and children arterial sites that have been used include the radial, brachial, femoral, superficial temporal, dorsalis pedis, posterior tibial, and umbilical arteries. These sites occasionally cannot be successfully cannulated percutaneously or by cutdown and are not without potential complications or time use limitations [14]. In this article we describe a technique using the internal mammary artery (IMA) that provides reliable access and continuous blood pressure monitoring. It is a technique that is easy and safe to perform and could be a useful alternative for the pediatric cardiac surgeon when a sternotomy or thoracotomy incision is planned.
Fig 1. The internal mamma y arte y is ligated distally and the catheter is passed through the abdominal wall.
abdominal wall using nonabsorbable suture. Next, the catheter is connected to an arterial pressure line to check the waveform and ability to withdraw blood. After the cardiac surgical procedure is completed, the chest is closed in the routine fashion. The postoperative chest roentgenogram should confirm line placement and location (Fig 3). When the arterial line is no longer needed it is simply pulled out and the suture on the anterior chest wall is tied, compressing the IMA against the chest wall. The anterior chest wall suture can be cut and removed before discharge from the hospital.
Technique The patient is placed in the supine position with a small roll placed transversely beneath the shoulders. The chest is opened using a midline sternotomy incision. A rake is used to retract the sternal edge superiorly. The IMA is then identified and isolated for approximately 2 cm in a region inferior to the nipple. The IMA is then ligated distally. Using a 13-gauge hollow-core needle a 3.5F umbilical artery catheter is then passed through the fascia exiting on the anterior abdominal wall (Fig 1).A doublearmed nonabsorbable suture is looped around the IMA, and both ends are brought out through the chest wall on either side of the IMA. The free ends of the suture will be externally located approximately 1 cm apart below the nipple. A transverse arteriotomy is made and the catheter inserted so the tip will be in the subclavian artery (Fig 2). The suture on the chest wall is tightened to prevent any backbleeding. The catheter is then secured on the anterior Accepted for publication July 29, 1993 Address reprint requests to Dr Slaughter, VA Medical Center, Surgical Service (112), One Veterans Dr, Minneapolis, MN 55417.
0 1993 by The Society of Thoracic Surgeons
Comment Vascular access in infants and children, particularly infants requiring repeat operations, may be limited due to previous cannulation or complications associated with attempted access. We have used this new technique in
Fig 2. Suture encircles the internal mammary a r t e y and the free ends are passed through the chest wall. The catheter is inserted under direct vision.
0003-4975/93/$6.00
1422
HOW TO DO IT SLAUGHTER ET AL IMA FOR ARTERIAL MONITORING
Ann Thorac Surg 1993;561421-2
artery cannulation. Under these circumstances the IMA can be a useful alternative. Either the right or left IMA can be used for monitoring. If future coronary revascularization is a concern then the right IMA should be used. The catheter is inserted under direct vision, and at termination the proximal half of the IMA and its perforating vessels are preserved. The catheter can be inserted safely and provides accurate blood pressure monitoring and access for blood drawing. We have used this technique in 6 patients with difficult arterial access without any complications. We believe this is a useful technique for the infant with difficult arterial access undergoing a cardiac procedure.
References
Fig 3. Chest roentgenogram showing the tip of the catheter at the junction of the internal mammary artery and the subclavian artery.
infants who have had previous cardiac procedures that also involved cutdowns in the extremities for arterial access and complications from attempted femoral
1. Henry CG, Cutierrez F, Lee JT, et al. Aortic thrombosis presenting as congestive heart failure: an umbilical artery catheter complication. J Pediatr 1981;98:820-2. 2. Bull MJ, Schreiner RL, Garg BP, et al. Neurologic complications following temporal artery catheterization. J Pediatr 1980; 96:10713. 3. Mayer T, Matlak ME, Thompson JA. Necrosis of the forearm following radial artery catheterization in a patient with Reye’s syndrome. Pediatrics 1980;65:141-3. 4, Galvis AG, Donah00 JS, White JJ. An improved technique for catheterization in infants and &adren. Crit prolonged Care Med 1976;416&9.
Establishing and maintaining arterial access in pediatric cardiac operations is a frequent and sometimes frustrating problem. We have modified a procedure commonly used in our research laboratory for arterial pressure monitoring and applied it successfully to the pediatric cardiac surgical patient. The internal mammary artery can provide reliable arterial access in the postoperative period. (Ann Thorac Surg 1993;56:1421-2)
A
n indwelling arterial catheter allows continuous arterial blood pressure monitoring and access for routine laboratory tests and measurement of arterial blood gas values. In infants and children arterial sites that have been used include the radial, brachial, femoral, superficial temporal, dorsalis pedis, posterior tibial, and umbilical arteries. These sites occasionally cannot be successfully cannulated percutaneously or by cutdown and are not without potential complications or time use limitations [14]. In this article we describe a technique using the internal mammary artery (IMA) that provides reliable access and continuous blood pressure monitoring. It is a technique that is easy and safe to perform and could be a useful alternative for the pediatric cardiac surgeon when a sternotomy or thoracotomy incision is planned.
Fig 1. The internal mamma y arte y is ligated distally and the catheter is passed through the abdominal wall.
abdominal wall using nonabsorbable suture. Next, the catheter is connected to an arterial pressure line to check the waveform and ability to withdraw blood. After the cardiac surgical procedure is completed, the chest is closed in the routine fashion. The postoperative chest roentgenogram should confirm line placement and location (Fig 3). When the arterial line is no longer needed it is simply pulled out and the suture on the anterior chest wall is tied, compressing the IMA against the chest wall. The anterior chest wall suture can be cut and removed before discharge from the hospital.
Technique The patient is placed in the supine position with a small roll placed transversely beneath the shoulders. The chest is opened using a midline sternotomy incision. A rake is used to retract the sternal edge superiorly. The IMA is then identified and isolated for approximately 2 cm in a region inferior to the nipple. The IMA is then ligated distally. Using a 13-gauge hollow-core needle a 3.5F umbilical artery catheter is then passed through the fascia exiting on the anterior abdominal wall (Fig 1).A doublearmed nonabsorbable suture is looped around the IMA, and both ends are brought out through the chest wall on either side of the IMA. The free ends of the suture will be externally located approximately 1 cm apart below the nipple. A transverse arteriotomy is made and the catheter inserted so the tip will be in the subclavian artery (Fig 2). The suture on the chest wall is tightened to prevent any backbleeding. The catheter is then secured on the anterior Accepted for publication July 29, 1993 Address reprint requests to Dr Slaughter, VA Medical Center, Surgical Service (112), One Veterans Dr, Minneapolis, MN 55417.
0 1993 by The Society of Thoracic Surgeons
Comment Vascular access in infants and children, particularly infants requiring repeat operations, may be limited due to previous cannulation or complications associated with attempted access. We have used this new technique in
Fig 2. Suture encircles the internal mammary a r t e y and the free ends are passed through the chest wall. The catheter is inserted under direct vision.
0003-4975/93/$6.00
1422
HOW TO DO IT SLAUGHTER ET AL IMA FOR ARTERIAL MONITORING
Ann Thorac Surg 1993;561421-2
artery cannulation. Under these circumstances the IMA can be a useful alternative. Either the right or left IMA can be used for monitoring. If future coronary revascularization is a concern then the right IMA should be used. The catheter is inserted under direct vision, and at termination the proximal half of the IMA and its perforating vessels are preserved. The catheter can be inserted safely and provides accurate blood pressure monitoring and access for blood drawing. We have used this technique in 6 patients with difficult arterial access without any complications. We believe this is a useful technique for the infant with difficult arterial access undergoing a cardiac procedure.
References
Fig 3. Chest roentgenogram showing the tip of the catheter at the junction of the internal mammary artery and the subclavian artery.
infants who have had previous cardiac procedures that also involved cutdowns in the extremities for arterial access and complications from attempted femoral
1. Henry CG, Cutierrez F, Lee JT, et al. Aortic thrombosis presenting as congestive heart failure: an umbilical artery catheter complication. J Pediatr 1981;98:820-2. 2. Bull MJ, Schreiner RL, Garg BP, et al. Neurologic complications following temporal artery catheterization. J Pediatr 1980; 96:10713. 3. Mayer T, Matlak ME, Thompson JA. Necrosis of the forearm following radial artery catheterization in a patient with Reye’s syndrome. Pediatrics 1980;65:141-3. 4, Galvis AG, Donah00 JS, White JJ. An improved technique for catheterization in infants and &adren. Crit prolonged Care Med 1976;416&9.