European Journal of Cardiovascular Medicine

Extensive aortic disease, such as atherosclerosis with aneurysms or dissections that involve the ascending aorta, can complicate the choice of a cannulation site for cardiopulmonary bypass. To date, the standard peripheral arterial cannulation site has been the common femoral artery; however, this approach carries the risk of atheroembolism due to retrograde aortic perfusion, or it is undesirable because of severe iliofemoral disease. Arterial perfusion through the axillary artery provides sufficient antegrade aortic flow, is more likely to perfuse the true lumen in the event of aortic dissection, and is

associated with fewer atheroembolic complications. [1,2,3]

Arterial cannulation through the axillary artery may present a valid alternative in these circumstances, and in cases of aortic dissection, at least in regard to the vessels that perfuse the cerebrum, it perfuses the true lumen more reliably. [4,5] It is easy and safe to perform, and it provides sufficient arterial inflow during CPB. In this case series we report our preliminary experience with axillary artery cannulation through a small infraclavicular incision for repair of acute type A aortic dissections and ascending aortic aneurysms.

This is a retrospective study of 20 patients who underwent direct Right axillary artery cannulation for specific indications at NIMS hospital, Hyderabad from January 2021 through October 2023.

Inclusion criteria: Patients who underwent direct Right axillary artery cannulation for specific indications.

Exclusion criteria: Significant proximal ipsilateral subclavian stenosis, Presence of significant atheroma or calcification or dissection in axillary artery

We accessed medical records of these patients and assessed for the following post operative complications: 1. Distal limb malperfusion 2. Local wound complications 3. Neurological complications pertaining to Brachial Plexus 4: Neurological complications pertaining to the Central Nervous System.

Procedure: A 5 cm transverse skin incision was made approximately 2cm below lateral 1/3^rd of the right clavicle. Subcutaneous tissue, pectoralis major, minor muscles were divided. The artery was then looped with umbilical tapes. Vessel branches divided or double looped with 1 silk. Axillary artery was clamped proximally and distally and incised longitudinally in between the clamps and directly cannulated with straight cannula. Either 18 or 20 Fr provide full cardiopulmonary bypass flow.

1. Axillary artery exposure Cannulation

1. Pericardial patch repair

Figure-1: Intra operative photos of right axillary artery cannulation through infraclavicular incision with 18fr cannula in situ

The proximal umbilical tape is snared and secured to the cannula. The arterial cannula is then connected to an arterial line of cardiopulmonary bypass. After the procedure the cannulation site is repaired with pericardial patch with 6-0 polypropylene sutures.

Twenty patients had undergone direct axillary artery cannulation during the study period for different aortic pathologies of which 14 (70%) were male and 6 (30%) female.

12 (60%) patients were operated for acute aortic dissection, 4(20%) for chronic aortic dissection and 4(20%) for aortic aneurysm.

Patients were distributed among all age groups youngest being 29 years oldest being 70 years with most of the patients in their 3^rd and 4^th decade of life.

None of the patients who underwent direct Right axillary cannulation for surgery for aortic dissection and arch aneurysms had any neurological complications, limb ischemia or wound infection. 2 patients had transient neurological dysfunction of limb which settled with physiotherapy. 3 patients died during their ICU stay due to low cardiac output with mortality at 15%. Mean ICU stay was 3 days. Post operative recovery was satisfactory in these patients. The most common post operative complication is pain at wound site.

Axillary artery cannulation ensured adequate arterial inflow during bypass in all cases.

Table-1:

Sabik and colleagues [6] study popularized the technique of using the right axillary artery for arterial cannulation for complex adult cardiac surgeries. Antegrade selective cerebral perfusion (ASCP) through the right axillary artery has proved to be a safe and effective method for cerebral protection in aortic surgery. The right axillary artery is now preferred for aortic surgeries. Another site for peripheral cannulation is femoral artery. But it is associated with more complications like lower limb ischemia, compartment syndrome, wound complications. Because axillary artery cannulation is associated with less complications, it has now become the preferred site for peripheral cannulation. The axillary artery is generally free from atherosclerosis, in comparison with the femoral arteries, and the axillary artery is rarely affected by dissection. As compared to the case of the femoral artery, surgical exploration of the axillary artery is easy to perform.

Axillary cannulation includes side-graft and direct cannulation. Side-graft cannulation involves sewing an 8–10 mm graft to axillary artery, with less cannula resistance and consequently decreased risk of peripheral damage. During circulatory arrest for aortic arch repair, the side graft cannulation allowed unilateral antegrade cerebral perfusion

by clamping the proximal innominate artery and indirect pressure monitoring by right radial artery catheterization. However, side-graft cannulation needs additional 15–30min and is technically demanding. In addition, this technique may exacerbate further malperfusion or arch dissection.

Studies by Ohria et al. [7] and Carino et al [8] indicate that there are no differences between two cannulation methods, and direct cannulation can be less time consuming. Puiu et al. demonstrated that the side graft technique required more packed red blood cells than the direct cannulation technique. As many surgeons have experienced, there is significant leakage from the anastomosis during cardiopulmonary bypass when using the side graft technique. In addition, hyperperfusion to the ipsilateral arm often happens, which may need adjustment of flow distal to the anastomosis in the side graft technique, while direct axillary cannulation technique does not require this.

Neri and colleagues [9] reported that they preferred left axillary artery cannulation, because the left subclavian artery has its origin separate and downstream from the carotid artery. They suggested that the brachiocephalic trunk was often obstructed by expansion of the false lumen in type A aortic dissection, but we did not encounter any such complication in our study.

Svensson et al [10] reported that higher ASCP pressure was associated with greater risk of stroke and neurocognitive deficit. Direct axillary cannulation can cause increased antegrade cerebral flow pressure. In our study  no patients had post operative neurocognitive deficit .

Sabik's group compared direct right axillary artery cannulation with sidegraft cannulation in regard to cannulation-related morbidity. They evaluated 399 patients who underwent 399 axillary artery cannulations. The axillary artery was cannulated directly in 212 (54%) instances and with a side graft in 187 (48%). Side-graft cannulation significantly reduced brachial plexus injury, axillary artery injury, arm ischemia, and aortic dissection. They concluded that cannulation with a side graft was associated with less cannulation-related morbidity than was direct cannulation, and they recommended the routine use of a side graft whenever axillary artery cannulation was indicated. In our study we did not encroach upon any cannulation related complication.[11]

Direct right axillary cannulation avoids suture line leakage and blood leakage through grafts. Even in a setting of extensive aortic and innominate artery disease, the axillary artery is rarely affected and provides an excellent site for safe antegrade cerebral perfusion, which may play a role in preventing embolic stroke. Also it is technically easy and less time consuming compared to side graft.

Direct right axillary cannulation is a safe and effective procedure without ischemic, neurological complications and wound infection for aortic surgeries. Potential benefits of direct axillary artery cannulation technique over side-graft technique includes less bleeding during cardiopulmonary bypass, no need to control distal flow in the ipsilateral arm, and no foreign body left at the completion of the procedure. Less blood transfusions, less time consuming and technically simple.

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