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Brain Protection by Using Innominate Artery Cannulation During Aortic Arch Surgery
HOW TO DO IT
Brain Protection by Using Innominate Artery Cannulation During Aortic Arch Surgery Shangyi Ji, MD, Jianan Yang, MD, Xiaoqing Ye, MD, and Xiaolei Wang, MD Department of Surgery, Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen, China
FEATURE ARTICLES
The innominate artery cannulation (IAC) through the same sternotomy incision was used for 68 patients with aneurysm, involving the ascending aorta or the aorta arch. The IAC can get adequate flows during cooling and re-warming of cardiopulmonary bypass. It can also provide sufficient antegrade perfusion for brain during hy-
pothermia circulation arrest. There is no relative complication noted for the technique, and we believe it is a simple and effective alternative.
C
plaques, stenosis, and other artery lesions. The patient lies in the supine position. A midline sternotomy is performed with the upper end of the incision being made higher. After opening the pericardium, systolic blood pressure is lowered to 100 mm Hg with a vasodilator to facilitate gentle palpation of the presence of atherosclerosis in the entire ascending aorta, aortic arch, and arch vessels, especially the innominate artery. This approach should be forsaken in patients with obvious atherosclerosis or palpable plaques. According to the size of the innominate artery, a 22-French or 24-French wirereinforced flexible short-tipped cannula is used. Then 4-0 Prolene (Ethicon, Somerville, NJ) double pursestring sutures are applied to the innominate artery for routine aortic cannulation. The innominate artery is then stabbed, and the cannula is introduced in the usual fashion with the tip pointing toward the aortic arch. The pursestrings are held snug and the cannula is affixed to the tourniquets. During the initial cooling and final re-warming, the cannula tip should be oriented toward the aortic arch (Fig 1). This allows higher flow and less resistance to CPB. During systemic circulatory arrest and selective antegrade cerebral perfusion, the cannula tip should be turned gently toward the head, and a vascular clamp is applied proximal to the cannula (Fig 2). Using a straight cannula, this orientation step can be omitted. The selective perfusion flow can be monitored by right radial artery pressure during the entire process. The procedures included hemi-arch repair plus Bentall procedure in 46 patients, hemi-arch repair plus Wheat’s procedure in 8 patients, arch replacement in 3, ascending aorta grafting in 6, and hemi-arch repair plus Cabrol’s procedure in 5. All of the patients were discharged, except 2 (1 who died from bleeding on the operating day and the other who died from pneumonia on postoperative day 9). The CPB time was 87⬃167 minutes (128.5 ⫾ 37.5 minutes); aortic cross clamping time was 57⬃128 minutes (89 ⫾ 21 minutes). The CPB flows were 2.1⬃2.7 L/m2/min (2.38 ⫾ 0.85 L/m2/min). The hypothermic circulation arrest (HCA) time was 17⬃48 minutes (29 ⫾ 11 min). The right radial pressure was maintained at 43⬃78
hoosing the proper cannulating site for arterial return is an important point during the conduct of cardiopulmonary bypass (CPB). The ascending aorta is the usual site of arterial inflow for CPB. When disease involves the ascending aorta or the aortic arch, or in some redo cases, the ascending aortic cannulation is unavailable. Femoral artery cannulation may be an alternative for type A dissection aneurysm, but it has many drawbacks. The artery, especially in women, limits the size of the cannula used. Atherosclerosis of the descending aorta and iliac artery may cause cerebral embolization. Hypoperfusion is also a major concern. Thus, axillary artery cannulation is introduced [1–7]. 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 [8]. But there exists a potential danger of the brachial plexus injury and limb ischemia [9]. Cable of the axillary artery also limits the size of the cannula, as well as bypass flow, and an additional incision is required. Besides, during selective antegrade cerebral perfusion, it is hard to monitor the perfusion pressure. So the innominate artery cannulation is brought into consideration [10, 11].
Technique From June 2002 to May 2007, 68 cases with lesions involving the ascending aorta or the aortic arch were cannulated in the innominate artery for surgery in our hospital. Ages varied from 23 to 69 years (mean age, 46.2 ⫾ 21.7 years), and 50 patients were male (73.5%). All of the 68 patients did not have peripheral vascular disease noted. Echocardiography, computed tomography, or magnetic resonance imaging of the innominate artery is checked before an operation to exclude atherosclerosis, Accepted for publication March 3, 2008. Address correspondence to Dr Ji, Sun Yat-sen Cardiovascular Hospital, 1021 Dongmen N Rd, Shenzhen, 518020, China; e-mail: jonathan.wu@ atsmedical.com.
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2008;86:1030 –2) © 2008 by The Society of Thoracic Surgeons
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.03.044
Ann Thorac Surg 2008;86:1030 –2
HOW TO DO IT JI ET AL BRAIN PROTECTION DURING AORTIC ARCH SURGERY
1031
mm Hg during the HCA. At the end of the HCA, the SO2 in the mixed blood was maintained between 0.58⬃0.75. There was no neurologic complications (including coma, lethargy, convulsion, paraplegia, hemiparalysis, paresthesia, and anesthesias) noted. The patients regained full consciousness within 2 to 10.6 hours (mean ⫾ standard deviation, 5.7 ⫾ 3.1 hours). There was no renal dysfunction noted with the routine use of 250 mL mannitol, 5 to 10 mg furosemide, and 10 mg dexamethasone treatment. Complications included three reinterventions for bleeding, eight pleural effusion cases, and one ventricular arrhythmia.
Comment From June 2002 to May 2007, 68 patients were operated on in our hospital using the IAC technique. The diagnoses and surgical procedures are mentioned previously. In all cases, adequate CPB flow of 2.38 L/m2/min was achieved. There was no difference between right and left radial arterial pressures during the cooling or rewarming phases, as monitored in 18 patients. The cannula in the innominate artery and its tip direction did not cause any significant difference in perfusion pressure. There were 66 patients who survived from the operation, and none had a cerebrovascular accident. No postoperative complications related to innominate artery cannulation (IAC) was noted. All patients regained full consciousness soon after the operation, without any
noticeable neurologic sequelae. Two patients died in the hospital because of complications unrelated to IAC. Although there is increasing evidence that femoral or axillary artery cannulation has become the routine approach for surgery involving the ascending aorta and aortic arch, an additional incision, interruption perfusion of the cannulated limbs, and loss of monitoring during cerebral perfusion remain to be of concern. Potential brachial plexus injuries and the small diameter of the axillary artery may prolong the course of the procedure and result in additional complications [5]. Direct cannulation could cause trauma or dissection of the axillary artery [12]. Sabik and colleagues [4] reported that cannulation with a side graft was associated with less morbidity than direct cannulation. Compared with axillary artery cannulation, IAC carries some benefits. No additional incision is needed, and the same technique and same size of cannula are used, as in the ascending aortic cannulation. The cannula tip can be oriented as needed. Cerebral perfusion pressure can be monitored continuously with a right radial arterial line. Ascending aortic surgery or aorta arch reconstruction involving open distal anastomosis or circulatory arrest are the indications. In root or arch surgery, when the lesions preclude the ascending aortic cannulation, IAC is also a good option. The potential danger for cerebral embolism still remains; therefore, the innominate artery should be free of disease. The IAC technique should be forsaken at any evidence of atherosclerosis, stenosis, or plaques in the
Fig 2. Another cross clamp is placed proximal to the initial site of the innominate artery for selective brain antegrade perfusion. (Operating picture on left and drawing on right.)
FEATURE ARTICLES
Fig 1. For cooling and re-warming, the cross clamp is placed at the ascending aorta. (Operating picture on left and the drawing on right.)
1032
HOW TO DO IT JI ET AL BRAIN PROTECTION DURING AORTIC ARCH SURGERY
innominate artery. Preoperative computed tomography and ultrasonic scanning usually provide important information. Before cannulation, intraoperative palpation of the ascending aorta, aortic arch, and arch vessels is of much importance. When IAC is done, care must be taken in changing tip direction and cross clamping the innominate artery for selective brain perfusion. Gentle handling and transient flow reduction might be the optimal approach to avert adverse outcomes; this is preferable in ascending aortic aneurysm, dissection, or in any operation demanding HCA and distal open arch anastomosis. The IAC technique seems to be simple, safe, reliable, and effective.
References 1. Matrda H, Ino Y, Matsukawa R, et al. Mid-term results of the surgery for aortic arch aneurysm. Kyobu Geka 2002;55: 340 – 6. 2. Swain JA, Mcdonald TJ, Griffth PK, et al. Low-flow hypothermic cardiopulmonary bypass protectes the brain. J Thorac Cardiovasc Surg 1991;102:76 – 83. 3. Bachel J, Guilmel D. Brain protection during surgery of the aortic arch. J Card Surg 2002;17:115–24. 4. Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients
Ann Thorac Surg 2008;86:1030 –2
5.
6.
7.
8.
9.
10. 11.
12.
with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885–91. 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. 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. 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. Strauch JT, Spielvogel D, Lauten A, et al. Technical advances in total aortic arch replacement. Ann Thorac Surg 2004,77: 581–90. Sabik JF, Nemeh H, Lytle BW, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004,77:1315–20. Banbury MK, Cosgrove DM 3rd. Arterial cannulation of the innominate artery. Ann Thorac Surg 2000;69:957. Shangyi-ji, Jianan-yang, Changchun-chen. Brain protection by using innominate artery cannulation during aortic arch surgery. Chin J Thorac Cardiovasc Surg 2006; 22:424 –5. 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.
FEATURE ARTICLES
Brain Protection by Using Innominate Artery Cannulation During Aortic Arch Surgery Shangyi Ji, MD, Jianan Yang, MD, Xiaoqing Ye, MD, and Xiaolei Wang, MD Department of Surgery, Shenzhen Sun Yat-sen Cardiovascular Hospital, Shenzhen, China
FEATURE ARTICLES
The innominate artery cannulation (IAC) through the same sternotomy incision was used for 68 patients with aneurysm, involving the ascending aorta or the aorta arch. The IAC can get adequate flows during cooling and re-warming of cardiopulmonary bypass. It can also provide sufficient antegrade perfusion for brain during hy-
pothermia circulation arrest. There is no relative complication noted for the technique, and we believe it is a simple and effective alternative.
C
plaques, stenosis, and other artery lesions. The patient lies in the supine position. A midline sternotomy is performed with the upper end of the incision being made higher. After opening the pericardium, systolic blood pressure is lowered to 100 mm Hg with a vasodilator to facilitate gentle palpation of the presence of atherosclerosis in the entire ascending aorta, aortic arch, and arch vessels, especially the innominate artery. This approach should be forsaken in patients with obvious atherosclerosis or palpable plaques. According to the size of the innominate artery, a 22-French or 24-French wirereinforced flexible short-tipped cannula is used. Then 4-0 Prolene (Ethicon, Somerville, NJ) double pursestring sutures are applied to the innominate artery for routine aortic cannulation. The innominate artery is then stabbed, and the cannula is introduced in the usual fashion with the tip pointing toward the aortic arch. The pursestrings are held snug and the cannula is affixed to the tourniquets. During the initial cooling and final re-warming, the cannula tip should be oriented toward the aortic arch (Fig 1). This allows higher flow and less resistance to CPB. During systemic circulatory arrest and selective antegrade cerebral perfusion, the cannula tip should be turned gently toward the head, and a vascular clamp is applied proximal to the cannula (Fig 2). Using a straight cannula, this orientation step can be omitted. The selective perfusion flow can be monitored by right radial artery pressure during the entire process. The procedures included hemi-arch repair plus Bentall procedure in 46 patients, hemi-arch repair plus Wheat’s procedure in 8 patients, arch replacement in 3, ascending aorta grafting in 6, and hemi-arch repair plus Cabrol’s procedure in 5. All of the patients were discharged, except 2 (1 who died from bleeding on the operating day and the other who died from pneumonia on postoperative day 9). The CPB time was 87⬃167 minutes (128.5 ⫾ 37.5 minutes); aortic cross clamping time was 57⬃128 minutes (89 ⫾ 21 minutes). The CPB flows were 2.1⬃2.7 L/m2/min (2.38 ⫾ 0.85 L/m2/min). The hypothermic circulation arrest (HCA) time was 17⬃48 minutes (29 ⫾ 11 min). The right radial pressure was maintained at 43⬃78
hoosing the proper cannulating site for arterial return is an important point during the conduct of cardiopulmonary bypass (CPB). The ascending aorta is the usual site of arterial inflow for CPB. When disease involves the ascending aorta or the aortic arch, or in some redo cases, the ascending aortic cannulation is unavailable. Femoral artery cannulation may be an alternative for type A dissection aneurysm, but it has many drawbacks. The artery, especially in women, limits the size of the cannula used. Atherosclerosis of the descending aorta and iliac artery may cause cerebral embolization. Hypoperfusion is also a major concern. Thus, axillary artery cannulation is introduced [1–7]. 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 [8]. But there exists a potential danger of the brachial plexus injury and limb ischemia [9]. Cable of the axillary artery also limits the size of the cannula, as well as bypass flow, and an additional incision is required. Besides, during selective antegrade cerebral perfusion, it is hard to monitor the perfusion pressure. So the innominate artery cannulation is brought into consideration [10, 11].
Technique From June 2002 to May 2007, 68 cases with lesions involving the ascending aorta or the aortic arch were cannulated in the innominate artery for surgery in our hospital. Ages varied from 23 to 69 years (mean age, 46.2 ⫾ 21.7 years), and 50 patients were male (73.5%). All of the 68 patients did not have peripheral vascular disease noted. Echocardiography, computed tomography, or magnetic resonance imaging of the innominate artery is checked before an operation to exclude atherosclerosis, Accepted for publication March 3, 2008. Address correspondence to Dr Ji, Sun Yat-sen Cardiovascular Hospital, 1021 Dongmen N Rd, Shenzhen, 518020, China; e-mail: jonathan.wu@ atsmedical.com.
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2008;86:1030 –2) © 2008 by The Society of Thoracic Surgeons
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.03.044
Ann Thorac Surg 2008;86:1030 –2
HOW TO DO IT JI ET AL BRAIN PROTECTION DURING AORTIC ARCH SURGERY
1031
mm Hg during the HCA. At the end of the HCA, the SO2 in the mixed blood was maintained between 0.58⬃0.75. There was no neurologic complications (including coma, lethargy, convulsion, paraplegia, hemiparalysis, paresthesia, and anesthesias) noted. The patients regained full consciousness within 2 to 10.6 hours (mean ⫾ standard deviation, 5.7 ⫾ 3.1 hours). There was no renal dysfunction noted with the routine use of 250 mL mannitol, 5 to 10 mg furosemide, and 10 mg dexamethasone treatment. Complications included three reinterventions for bleeding, eight pleural effusion cases, and one ventricular arrhythmia.
Comment From June 2002 to May 2007, 68 patients were operated on in our hospital using the IAC technique. The diagnoses and surgical procedures are mentioned previously. In all cases, adequate CPB flow of 2.38 L/m2/min was achieved. There was no difference between right and left radial arterial pressures during the cooling or rewarming phases, as monitored in 18 patients. The cannula in the innominate artery and its tip direction did not cause any significant difference in perfusion pressure. There were 66 patients who survived from the operation, and none had a cerebrovascular accident. No postoperative complications related to innominate artery cannulation (IAC) was noted. All patients regained full consciousness soon after the operation, without any
noticeable neurologic sequelae. Two patients died in the hospital because of complications unrelated to IAC. Although there is increasing evidence that femoral or axillary artery cannulation has become the routine approach for surgery involving the ascending aorta and aortic arch, an additional incision, interruption perfusion of the cannulated limbs, and loss of monitoring during cerebral perfusion remain to be of concern. Potential brachial plexus injuries and the small diameter of the axillary artery may prolong the course of the procedure and result in additional complications [5]. Direct cannulation could cause trauma or dissection of the axillary artery [12]. Sabik and colleagues [4] reported that cannulation with a side graft was associated with less morbidity than direct cannulation. Compared with axillary artery cannulation, IAC carries some benefits. No additional incision is needed, and the same technique and same size of cannula are used, as in the ascending aortic cannulation. The cannula tip can be oriented as needed. Cerebral perfusion pressure can be monitored continuously with a right radial arterial line. Ascending aortic surgery or aorta arch reconstruction involving open distal anastomosis or circulatory arrest are the indications. In root or arch surgery, when the lesions preclude the ascending aortic cannulation, IAC is also a good option. The potential danger for cerebral embolism still remains; therefore, the innominate artery should be free of disease. The IAC technique should be forsaken at any evidence of atherosclerosis, stenosis, or plaques in the
Fig 2. Another cross clamp is placed proximal to the initial site of the innominate artery for selective brain antegrade perfusion. (Operating picture on left and drawing on right.)
FEATURE ARTICLES
Fig 1. For cooling and re-warming, the cross clamp is placed at the ascending aorta. (Operating picture on left and the drawing on right.)
1032
HOW TO DO IT JI ET AL BRAIN PROTECTION DURING AORTIC ARCH SURGERY
innominate artery. Preoperative computed tomography and ultrasonic scanning usually provide important information. Before cannulation, intraoperative palpation of the ascending aorta, aortic arch, and arch vessels is of much importance. When IAC is done, care must be taken in changing tip direction and cross clamping the innominate artery for selective brain perfusion. Gentle handling and transient flow reduction might be the optimal approach to avert adverse outcomes; this is preferable in ascending aortic aneurysm, dissection, or in any operation demanding HCA and distal open arch anastomosis. The IAC technique seems to be simple, safe, reliable, and effective.
References 1. Matrda H, Ino Y, Matsukawa R, et al. Mid-term results of the surgery for aortic arch aneurysm. Kyobu Geka 2002;55: 340 – 6. 2. Swain JA, Mcdonald TJ, Griffth PK, et al. Low-flow hypothermic cardiopulmonary bypass protectes the brain. J Thorac Cardiovasc Surg 1991;102:76 – 83. 3. Bachel J, Guilmel D. Brain protection during surgery of the aortic arch. J Card Surg 2002;17:115–24. 4. Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients
Ann Thorac Surg 2008;86:1030 –2
5.
6.
7.
8.
9.
10. 11.
12.
with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885–91. 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. 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. 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. Strauch JT, Spielvogel D, Lauten A, et al. Technical advances in total aortic arch replacement. Ann Thorac Surg 2004,77: 581–90. Sabik JF, Nemeh H, Lytle BW, et al. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004,77:1315–20. Banbury MK, Cosgrove DM 3rd. Arterial cannulation of the innominate artery. Ann Thorac Surg 2000;69:957. Shangyi-ji, Jianan-yang, Changchun-chen. Brain protection by using innominate artery cannulation during aortic arch surgery. Chin J Thorac Cardiovasc Surg 2006; 22:424 –5. 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.
FEATURE ARTICLES