Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
Use of Axillary Cannulation for Simultaneous Endo-Occlusion and Antegrade Perfusion During Minimally Invasive Surgery
Farivar, Robert Saeid MD, PhD; Fernandez, Joss D. MD
From the Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Carver College of Medicine, Iowa City, IA USA.
Accepted for publication June 5, 2012.
Presented at the Annual Scientific Meeting of the 21st Century Cardiothoracic Surgical Society, February 17–19, 2011, Boca Raton, FL USA.
Disclosures: Robert Saeid Farivar, MD, PhD, is a consultant for Edwards Lifesciences, Irvine, CA USA. Joss D. Fernandez, MD, declares no conflict of interest.
Address correspondence and reprint requests to Robert Saeid Farivar, MD, PhD, University of Iowa Hospitals and Clinics, Carver College of Medicine, 200 Hawkins Drive, SE517GH, Iowa City, IA 52242 USA. E-mail: firstname.lastname@example.org.
Objective: We aimed to develop an antegrade arterial perfusion method that would allow a single suture line on the heart.
Methods: Using an 8-mm Dacron graft sewn to the right axillary artery, we performed antegrade arterial flow and simultaneous endo-occlusion, as well as the delivery of antegrade cardioplegia.
Results: Five patients underwent right axillary antegrade flow, with intention to use axillary endo-occlusion. There were no deaths, axillary artery injuries, or conversions to sternotomy. One patient who had a small (6 mm) axillary artery required femoral arterial balloon placement with axillary arterial flow. When using a 100-mm endoballoon, transesophageal echo alone is suitable for placement of the endoballoon. All patients are alive and doing well at least 1 year after surgery.
Conclusions: The right axillary artery is a suitable conduit for simultaneous endo-occlusion, antegrade flow, and antegrade cardioplegia delivery during mitral valve surgery.
Minimally invasive surgery (MIS) has been defined by retrograde arterial perfusion,1 and this strategy has been shown to have a small but significant doubling of the rate of stroke. Central aortic cannulation during sternotomy2 and right mini-thoracotomy is thought to be protective against stroke by establishing antegrade flow.3 Antegrade flow may minimize particulate matter swept into the great vessels4 and reduces the source of retrograde arterial perfusion and ascending aortic dissection.5
We aimed to develop a method of antegrade arterial perfusion, simultaneous endo-occlusion, and cardioplegia delivery, as well as a single suture line on the heart (using a Sondergaard groove or interatrial approach), during mitral valve surgery. We also aimed to do so in such a way that would minimize intrusion into the small limited working space in minimal-access incisions.
We initially used this strategy on patients who have calcified and/or small iliofemoral vessels who may be at high risk for femoral cannulation. We have previously described our approach6 and now present additional patients who have benefitted from this strategy during minimal incision surgery. We also present size criteria in the axillary artery for acceptable application of this technology for simultaneous endo-occlusion and flow.
METHODS AND RESULTS
Informed consent was obtained for this procedure. A standard right axillary exposure is carried out in the lateral third of the deltopectoral groove. After retracting the cephalic vein cranially, the pectoralis minor is divided. In the axillary fat pad, the artery is noted and is double snared with vessel loops. A longitudinal arteriotomy is made after 5000 U of heparin is administered. An 8-mm graft is sewn to the axillary artery with 5-0 Prolene. We have found that the side chimney graft should be left at least 13 cm in length. It is then skirted over an Endoreturn 23 Y arm graft (Edwards Lifesciences, Irvine, CA USA). This is secured with three silk ties (Fig. 1). Full systemic heparinization is then performed. After standard deairing, the Endoreturn cannula/Dacron assembly is attached to the arterial circuit. The entire apparatus is then sutured to the drapes, with care not to kink the Dacron chimney graft. Using a 100-cm endoclamp, it is advanced (optionally over a wire) into the ascending aorta (Fig. 2A). We have not used the left axillary approach.
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.
We report this strategy in our initial five patients (Table 1). There were no deaths, conversions to sternotomy, dissections, or axillary artery injuries. All patients are doing well after 1 year of surgery. We noted that a 7-mm right axillary artery was necessary for simultaneous endo-occlusion and antegrade flow in the artery. If the axillary was bigger than 7 mm, we used the axillary artery for antegrade flow and placed the endoballoon via the femoral artery in standard manner. We noted that the 65-cm balloon did not have the correct natural curve to easily traverse the ascending aorta, although it could be manipulated over a wire and fluoroscopy to the ascending aorta.
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
With the recent interest in transaortic valve implantation, the left9,10,11 axillary has been used as an access point for stented valve constructs. Both self-expanding9 and balloon-expandable valves10 have been implanted via the axillary with success. Indeed, the axillary has recently been described as a conduit site for intraaortic balloon counterpulsation in a series of patients.12 Endovascular treatment of the thoracic aorta via the axillary artery has also proven to be feasible.13 This demonstrates the feasibility of relatively large intraluminal constructs delivered via the axillary arteries to the ascending aorta.
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.
Antegrade perfusion; Endoballoon occlusion
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