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Ann Thorac Surg 1998;66:33-37
© 1998 The Society of Thoracic Surgeons

Original articles: cardiovascular

Arterial inflow via an axillary artery graft for the severely atheromatous aorta

Yvon R. Baribeau, MDa, Benjamin M. Westbrook, MDa, David C. Charlesworth, MDa, Christopher T. Maloney, MDa

a New England Heart Institute, Catholic Medical Center, Manchester, New Hampshire, USA

Address reprint requests to Dr Baribeau, 100 McGregor St, Manchester, NH 03102
e-mail: (baribeau{at}tiac.net)

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. Strategy for severe aortic atheromatous disease identified by intraoperative epiaortic ultrasound remains to be determined. We used axillary artery inflow through graft interposition in an attempt to avoid potential embolization.

Methods. Between July 1995 and June 1997, axillary artery inflow was used in 29 patients. Procedures performed were coronary artery bypass in 21 patients (3 with combined carotid endarterectomy), aortic valve replacement in 2, valve replacement plus coronary artery bypass in 4, atrial septal defect repair in 1, and arch replacement in 1 patient. Fibrillatory arrest was used in 16 patients and circulatory arrest was used in 16 patients for excision of mobile atheroma or arch reconstruction. Antegrade cerebral perfusion through the axillary artery graft was carried out in 11 patients.

Results. There were no brachial neurovascular complications. Two operative deaths occurred. Two patients had operative strokes and 2 more had postoperative stroke, all with resolution at late follow-up. There were no strokes in the subset of patients who had antegrade cerebral perfusion during circulatory arrest.

Conclusions. The axillary artery is an excellent site for arterial inflow. Furthermore, antegrade cerebral perfusion is easily accomplished during periods of circulatory arrest. Finally, graft placement avoids potential local neurovascular complications.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Many situations in cardiac and aortic operations demand use of a distant arterial site of cannulation for extracorporeal circulation inflow. The femoral artery has been the conventional site in the great majority of patients, despite known complications [1–3]. In our practice, routine use of epiaortic echography has created a greater need for distant arterial inflow site in patients with severely atherosclerotic ascending aorta to avoid embolic ischemic events including stroke [4]. We have experience with a modified axillary technique that gives us the added advantage of antegrade and selective cerebral perfusion as needed in cases of circulatory arrest.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Technique
Routine clinical history and physical examination is done before the operation, noticing any evidence of cerebral and peripheral ischemic symptoms. Physical examinations include bilateral brachial pressures and a gradient is noted significant if more than 15 mm Hg. If possible an arch angiogram is done. Significant gradients arise from distal axillary or brachial artery stenosis, but the axillary artery will not be used if a proximal ipsilateral significant stenosis is found before operation. Preoperative carotid Doppler is obtained in all patients more than 60 years old or with renal failure or significant neurovascular complications in the past.

At the time of operation, bilateral radial arterial lines are placed for pressure monitoring. A horizontal incision is made below the medial third of the right clavicle (Fig 1), or on the left if the right cannot be used. The pectoralis major fascia is incised and its fibers retracted exposing the axillary vein. The pectoralis minor, if seen, is retracted laterally. The axillary artery is easily exposed under the vein and gently mobilized for 2 cm. An umbilical tape is looped around the artery, and gentle traction applied. After heparinization a side-bite clamp is applied across the artery clamping the artery proximally and distally at the same time, and an 8-mm woven Dacron graft (Meadox Medicals, Inc, Oakland, NJ) or 8-mm Gelweave graft (Sulzer Vascutek USA, Austin, TX) is anastomosed with polypropylene suture 4-0 or 5-0 depending on the size of the artery. The graft is then clamped and the side-bite clamp released (Fig 2). Next it is connected to a 24F "arch" or flexible arterial cannula (Sarns 3M; Health Care, Ann Harbor, MI) and the pressure compared to the contralateral radial systemic pressure to confirm that there is no gradient. Venous outflow is obtained through regular fashion after sternotomy. Extracorporeal circulation is then established at 2.2 to 2.8 I · m2 · min-1 at normothermia. During extracorporeal circulation the systemic pressure is monitored through the contralateral radial line as pressure tends to be higher on the side of the axillary cannulation.



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  		Fig 1. Incision below the medial third of the clavicle allows access to the proximal axillary artery.

 


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  		Fig 2. Graft anastomosed end-to-side to the axillary artery.

 
If circulatory arrest is necessary, the patient is cooled down to 22°C and the innominate artery clamped while the flow is simply turned down at the desired level, usually 500 to 800 mL/min. The left common carotid can be clamped as well if no significant disease exists at the proximal segment (Fig 3). The brain perfusion pressure is monitored through the right radial artery during that time and kept at or below 50 mm Hg. When extracorporeal circulation is reestablished, the proximal innominate artery is released and the flow simply increased to 2.2 to 2.4 L · m2 · min-1 and the patient rewarmed. At the end of the procedure, the graft is clamped and cut a few millimeters above the anastomosis and oversewn with 4-0 polypropylene. It is important to avoid narrowing the axillary artery or creating a stump that could act as an aneurysm or source of emboli later.



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  		Fig 3. Selective antegrade cerebral perfusion is easily accomplished by clamping of the innominate and left common carotid arteries while lowering pump flow.

 
Patient population
Between July 20, 1995, and June 20, 1997, 29 consecutive patients with severe atherosclerosis of the ascending aorta or transverse arch underwent axillary artery graft placement for arterial inflow during cardiopulmonary bypass. There were 15 men and 14 women, with ages ranging from 46 to 84 years (mean, 69.6 years). Preoperative risk factors included hypertension in 20 (69%), diabetes mellitus in 7 (24%), and peripheral vascular disease in 20 (69%). A history of prior stroke, transient ischemic attack, or carotid operation was present in 17%, 7%, and 17% respectively (Table 1).


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  		Table 1. Cerebrovascular Comorbidities

 
Results of preoperative carotid ultrasound were available in 25 patients. Seven patients (28%) had unilateral stenosis more than 50%. Six patients (24%) had bilateral stenosis more than 50%. Operations were elective in 5 patients, urgent in 23, and emergent in 1. Primary operations were carried out in 22 patients, with secondary or tertiary procedures in 7 patients. The axillary artery was successfully used in all 29 patients, although 1 patient required localized endarterectomy for graft placement. The right axillary artery was used in 28 patients and the left in 1 patient. Coronary artery bypass only was performed in 15 patients (Table 2). Fibrillatory arrest was used in 11 of these patients for construction of distal anastomoses (mean number of grafts per patient, 4.7). Circulatory arrest was used in 12 of these patients, with 6 arch endarterectomies, 2 arch endarterectomies with patch aortoplasty, 1 ascending aorta and transverse arch replacement, and 1 arch inspection.


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  		Table 2. Details of Operations Performed

 
Combined carotid endarterectomy and coronary artery bypass was performed in 3 patients. All 3 of these patients underwent fibrillatory arrest with 1 patient also requiring arch endarterectomy for mobile atheromas.

Coronary artery bypass with arch vessel bypass was necessary in 2 patients. One patient required ascending aorta and partial arch replacement with bypass of the innominate. The other patient required arch vessel bypass and carotid to subclavian bypass for aberrant right subclavian artery. One patient had ascending aorta and arch replacement with concomitant coronary bypass for aneurysmal disease. Coronary artery bypass plus aortic valve replacement was carried out in 3 patients, with double valve replacement in 1. Isolated aortic valve replacement was performed in 2 patients. One patient had isolated arch replacement for symptomatic ulceration with embolism and an additional patient underwent closure of an atrial septal defect.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
There were no complications related to the technique of axillary artery cannulation. Specifically, no patient had vascular injury and there were no brachial plexus injuries.

Sixteen patients underwent circulatory arrest from 3.5 to 30 minutes, for an average time of 13.31 minutes. Antegrade cerebral perfusion was used in 11 of these patients without a stroke. There were two operative deaths (6.8%), both from multisystem dysfunction. There were two operative strokes (6.8%), both with good function at late follow-up, and two delayed strokes related to postoperative atrial fibrillation. Length of stay ranged from 5 to 26 days (mean, 10.9 days).


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
Stroke is a major cause of morbidity in cardiac operations and was responsible for 60% of the early postoperative mortality in one study [5]. Atherosclerosis of the ascending aorta has been related to the risk of stroke with [5, 6] and without [7, 8] a cardiac operation. Palpation of the aorta only has been shown unreliable in detecting significant atherosclerotic aortic disease [6, 9, 10], particularly in patients without calcification but where there is loose atherosclerotic involvement and greater risk of embolization [11].

Our immediate operative stroke rate was 6.8% and the total stroke rate was 13.6%. This compares favorably with the stroke rate seen without intervention in these patients, varying from 23% [5] to 50% [6]. Those 2 patients were in our early experience when a more aggressive approach toward debridement or endarterectomy of the aorta was used. They both recovered from the stroke without residual deficits. We now favor a more delicate approach with intervention on mobile segments only and with suction endarterectomy, unless the involvement is extensive and there is need for extracorporeal circulation and cardioplegia such as valve replacement. Greater use of the beating heart technique for coronary revascularization without extracorporeal circulation will surely influence us toward a noninterventional attitude, although a case can be made for removal of mobile debris with short circulatory arrest time, as the stroke rate on a patient with severe atherosclerosis of the ascending and transverse aorta is high [12]. Similarly, others have obtained excellent results with an even more aggressive approach [13].

Femoral cannulation is not always possible and can be complicated by distal obstructive and proximal embolic ischemic symptoms [1–3]. Citing autopsy work done by Lam and colleagues [14], Svensson and Crawford [15] already warned about its excessive use and the risk of dissection. It also necessitates repositioning of the cannula in cases of dissection to obtain antegrade aortic flow. Table 3 shows the different strategies when faced with severely atherosclerotic aorta in the operating room.


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  		Table 3. Strategies for Severe Atherosclerotic Aorta at the Time of Operation

 
Direct axillary artery cannulation has been described in the past by the Cleveland Clinic group [16]. Their series included 35 patients with 16 of them for severe aortic atherosclerosis. They favored direct cannulation and used a more lateral segment of the artery. Two of their patients had local complications including axillary artery thrombosis and brachial plexus paresis. We had no local complications related to the technique. By using a graft interposition technique and a more medial approach, we believe we can avoid these injuries. The brachial plexus roots are usually lateral and not seen or mobilized. The technique also avoids stenosis of the artery at closure by tailoring the proximal graft as a patch. The possibility of leaving excess graft and creating a cul-de-sac and eventual embolization source must be kept in mind. Our follow-up to date is short but no distal limb embolization has occurred.

Antegrade brain protection is not new and multiple variations have been used, including partial and complete head vessel perfusion. An alternative and standard technique in most centers is retrograde brain perfusion [17] through a superior vena cava cannula, with or without azygos vein clamping. This technique requires additional time and manipulation and may not be as effective for protection [18–20].

Our flow rate during circulatory arrest is based on normal physiology [21] and the studies by Tanaka and colleagues [22] at moderate hypothermia. On the basis of experimental and clinical data, they recommend a perfusion rate of 10 mL · kg-1 · min-1 at a pressure greater than 30 mm Hg or more for selective cerebral perfusion. There is concern for hyperperfusion if the left carotid is clamped, but we never observed high resistance complication such as hemorrhagic stroke. Still by monitoring the pressure from the right radial we control any hypertension by lowering the rate or opening the origin of the left carotid, which is never clamped until the arch has been opened and the ostium checked for any loose debris. Kouchoukos [23] also warned against clamping the brachiocephalic vessels. We also believe that part of the cerebral protective effect at that rate is from the significant retrograde washing effect through the left common carotid and subclavian arteries, preventing air and debris embolization. Additional protection is provided to the brain by hypothermia. More uniform brain cooling may also be obtained through axillary rather than femoral cannulation [24].

Finally, there is concern about the absent circle of Willis and incomplete perfusion of the contralateral hemisphere, but to date all patients showed significant bleeding from the contralateral carotid ostium, suggesting a functional circle. Preoperative evaluation by transcranial Doppler could be used to evaluate the circle of Willis in elective cases.

Our indications for this technique include a severely atherosclerotic or calcified aorta, planned circulatory arrest, type A aortic dissections, multiple prior sternotomies where bleeding on reentry is a concern, and more recently ministernotomy aortic and mitral valve replacement, where manubrium stability is preserved by allowing a lower sternotomy, as there is no need for aortic cannulation. Added advantage is antegrade cerebral flow through the same graft, which is a very quick and efficient way of assuring brain protection if circulatory arrest is needed. Particularly, the preservation of antegrade flow through the aorta after repair for type A dissection simplifies reconstruction by allowing a single cannulation site.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
We are grateful to Dr Andre Gervais of the Department of Anatomy, University of Montreal, for his help on axillary dissection.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

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  6. Ribakove G.H., Katz E.S., Galloway A.C., et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 1992;53:758-763.[Abstract]
  7. Davila-Roman V.G., Barzilai B., Wareing T.H., Murphy S.F., Schechtman K.B., Kouchoukos N.T. Atherosclerosis of the ascending aorta: prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke 1994;25:2010-2016.[Abstract]
  8. Amarenco P., Duyckaerts C., Tzourio C., Hénin D., Bousser M.G., Hauw J. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992;26:221-225.
  9. Davila-Roman V.G., Barzilai B., Wareing T.H., Murphy S.F., Kouchoukos N.T. Intraoperative ultrasonographic evaluation of the ascending aorta in 100 consecutive patients undergoing cardiac surgery. Circulation 1991;84(Suppl 3):47-53.
  10. Ohteki H., Itoh T., Natsuaki M., Minato N., Suda H. Intraoperative ultrasonic imaging of the ascending aorta in ischemic heart disease. Ann Thorac Surg 1990;50:539-542.[Abstract]
  11. Barzilai B., Marshall W.G., Jr, Saffitz J.E., Kouchoukos N. Avoidance of embolic complications by ultrasonic characterization of the ascending aorta. Circulation 1989;80(Suppl 1):275-279.
  12. Amarenco P., The French Study of Aortic Plaques in Stroke Group. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996;334:1216-1221.[Abstract/Free Full Text]
  13. Wareing T.H., Davila-Roman V.G., Barzilai B., Murphy S.F., Kouchoukos N.T. Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy for detection and treatment. J Thorac Cardiovasc Surg 1992;103:453-461.[Abstract]
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  16. Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D.M. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-891.[Abstract]
  17. Ueda Y., Miki S., Kusuhara K., Okita Y., Tahata T., Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31:553-558.[Medline]
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  19. Filgueiras C., Ryner L., Ye J., et al. Cerebral protection during moderate hypothermic circulatory arrest: histopathology and magnetic resonance spectroscopy of brain energetics and intracellular pH in pigs. J Thorac Cardiovasc Surg 1996;112:1073-1080.[Abstract/Free Full Text]
  20. Ye J., Yang L., Del Bigio M., et al. Retrograde cerebral perfusion provides limited distribution of blood to the brain: a study in pigs. J Thorac Cardiovasc Surg 1997;114:660-665.[Abstract/Free Full Text]
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H. B. Bittner and M. A. Savitt
Management of porcelain aorta and calcified great vessels in coronary artery bypass grafting with off-pump and no-touch technology
Ann. Thorac. Surg., October 1, 2001; 72(4): 1378 - 1380.
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T. Takahashi, Y. Shimazaki, T. Watanabe, T. Minowa, M. Koshika, K. Inui, J. Hosaka, and S. Toyama
Staged perfusion with an axillary artery graft and deep hypothermia during descending aortic replacement
J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 188 - 189.
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K. Yokota, T. Fujii, K. Kimura, T. Toriumi, and A. Sari
Life-Threatening Hypoxemic Respiratory Failure After Repair of Acute Type A Aortic Dissection: Successful Treatment with Venoarterial Extracorporeal Life Support Using a Prosthetic Graft Attached to the Right Axillary Artery
Anesth. Analg., April 1, 2001; 92(4): 872 - 876.
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Y. Moriyama, Y. Iguro, K. Hisatomi, G. Yotsumoto, H. Yamamoto, and R. Toda
Thoracic and thoracoabdominal aneurysm repair under deep hypothermia using subclavian arterial perfusion
Ann. Thorac. Surg., January 1, 2001; 71(1): 29 - 32.
[Abstract] [Full Text] [PDF]

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K. Imanaka, S. Kyo, H. Tanabe, H. Ohuchi, H. Asano, and Y. Yokote
Fatal intraoperative dissection of the innominate artery due to perfusion through the right axillary artery
J. Thorac. Cardiovasc. Surg., August 1, 2000; 120(2): 405 - 406.
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A. Gerdes, E. Joubert-Hubner, K. Esders, and H.-H. Sievers
Hydrodynamics of aortic arch vessels during perfusion through the right subclavian artery
Ann. Thorac. Surg., May 1, 2000; 69(5): 1425 - 1430.
[Abstract] [Full Text] [PDF]

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J. D. Whitlark, S. M. Goldman, and F. P. Sutter
Axillary artery cannulation in acute ascending aortic dissections
Ann. Thorac. Surg., April 1, 2000; 69(4): 1127 - 1128.
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R. G. Leyh
Reply
Ann. Thorac. Surg., January 1, 2000; 69(1): 317 - 317.
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Y. R. Baribeau and B. M. Westbrook
Axillary cannulation
Ann. Thorac. Surg., January 1, 2000; 69(1): 317 - 317.
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A. M. Gillinov, J. F. Sabik, B. W. Lytle, and D. M. Cosgrove
Axillary artery cannulation
J. Thorac. Cardiovasc. Surg., December 1, 1999; 118(6): 1153 - 1153.
[Full Text]

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Y. R. Baribeau, B. M. Westbrook, and D. C. Charlesworth
Axillary cannulation: First choice for extra-aortic cannulation and brain protection
J. Thorac. Cardiovasc. Surg., December 1, 1999; 118(6): 1153 - 1154.
[Full Text]