The 100-cm endoclamp (Edwards Lifesciences) is then advanced through the side arm and graft across the anastomosis. Fluoroscopy and a guidewire may be used, although this has not proved necessary; we routinely use echocardiography alone as long as the axillary artery is greater than 7 mm in diameter. We place the balloon in the cannula to allow the curve of the balloon to naturally advance into the ascending aorta. Once the balloon is in the ascending aorta, antegrade flow will prevent the balloon from occluding the innominate takeoff and provide antegrade cerebral perfusion. We routinely perform mitral valve repair via a video-assisted thoracoscopic approach similar to previous series.7 We use a 5-cm incision in the fourth intercostal space as a working port and place the camera in the same interspace and place a vent and CO2 two interspaces caudal (Fig. 1). At the conclusion of the case, we routinely suture the chimney very short in a double layer or staple the stump with a vascular load.
Minimally invasive surgery, as defined by retrograde arterial perfusion, has been documented to double the risk of stroke.1 This may be attributed to atheroma in the descending aorta and/or arch that is retrograde perfused into the brain. In addition, the spectre of femoral dissection with concomitant retrograde arterial flow has hampered MIS because it will magnify the problems of a simple dissection by potential propagation into the ascending aorta, with all the sequelae of an acute type A dissection.8 Several centers have gone to a central aortic or minimally invasive with an antegrade flow strategy to avoid these potential complications and have reported good results.2,4
Axillary cannulation is an accepted strategy for antegrade arterial flow and has been used for decades safely.14,15 It maintains antegrade flow in all regions except in the short segment of the axillary artery, and it is outside of the incision, which may be important in a crowded mini-thoracotomy incision. We have chosen to use a side branch on the axillary artery because it has been shown to minimize complications.16 Endo-occlusion and axillary cannulation may have advantages in reoperations, in which it is desirable to avoid dissection of the aorta.17,5 This may minimize damage to the pulmonary artery and the aorta because the transverse sinus may be adhesed to the pulmonary artery. An additional advantage of the endo-occlusion strategy is the ability to administer antegrade cardioplegia and potentially vent via the central lumen.
We have been able to successfully place the 100-cm endoclamp with only the use of transesophageal echocardiography. This is facilitated by the inherent curve of the catheter. The 65-cm endoclamp does not have the same curve and, as such, needed wire guidance with fluoroscopy for successful placement. We do not routinely use the 65-cm endoclamp because of the need for fluoroscopy during placement.
The axillary artery has a wide variability in adults, from 5 to 14 mm. The size of the endoclamp is 10.5 French, which is ∼3 mm. The tip of the catheter is somewhat larger because of the additional size of the collapsed balloon. We noted that a minimum size of 7 mm was necessary for the axillary artery to allow simultaneous flow and endo-occlusion, without excessively high line pressures. We found line pressures in excess of 400 mm Hg when a small (<7 mm) axillary artery was used for simultaneous endo-occlusion, and we routinely use a computed tomography angiogram scan for screening in all patients. For those patients with a small axillary artery, a strategy that we have used is to place arterial antegrade flow via the right axillary artery and use a 19-French cannula in the femoral artery. This minimizes the threat of retrograde arterial dissection, although it does introduce an additional incision. Cannulation of the axillary artery with a Dacron side graft chimney has been shown to reduce complications,16 and we have used this in all our cases.
We have used this strategy selectively in patients whose descending aorta was deemed hostile for retrograde arterial perfusion, as well as in Marfan patients during reoperations in whom we did not wish to cannulate the ascending aorta (Table 1, patient 5). These included patients with small iliac systems6 (Table 1, patient 1), those with greater than 270 degree calcifications at the iliac bifurcation (especially if bilateral), those in whom one iliac artery is very small, and others who are critical, for example, those in whom the contralateral limb is amputated with a diminutive vessel (Table 1, patient 4). To date, we have had no complications from the axillary strategy. It is unknown whether a nonselective strategy in which the axillary artery is used for all MISs would have superior outcomes.
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This is a small case series that describes the use of antegrade axillary perfusion to facilitate minimally invasive valve surgery. This strategy allows for antegrade arterial perfusion, with simultaneous endoaortic occlusion and cardioplegia delivery through an 8-mm graft sewn to the axillary artery. It would be a particularly advantageous technique in elderly patients and those with peripheral vascular disease in whom femoral cannulation and retrograde perfusion may be problematic. Larger series will be needed to fully evaluate its effectiveness and safety.