The axillary artery is recognized as an excellent site to initiate arterial inflow for CPB. Studies that evaluate the outcome of axillary artery cannulation show low operative mortality and morbidity rates.4,5
The axillary artery is especially useful in circumstances such as type A dissection, high-grade atherosclerosis of the ascending aorta and arch, and complex aortic procedures and in the presence of a porcelain aorta.
Not only does axillary artery perfusion minimize the risks of embolic complications related to femoral perfusion when the ascending aorta is unavailable for cannulation, it facilitates the initiation of antegrade cerebral perfusion. Moreover, local neurovascular and infectious complications remain low—less than 5% in all series.6,7
Two methods for axillary artery cannulation have been described: direct cannulation and the interposition of a side graft. Both techniques have been shown to be reliable and safe.4,8
Both patients in the present series were cannulated by the side-graft technique, and a residual graft stump was left after discontinuation of CPB.
Because of the increased use of the axillary artery for cannulation, patients with previous cannulation at this site who require reoperation will be encountered more and more frequently. The present report describes the cases of 2 patients who had undergone axillary artery cannulation for complex aortic surgery and who presented later with complications related to that surgery. In both cases, the size of the pseudoaneurysm precluded a safe sternal reentry, unless deep hypothermia was induced by peripheral CPB cannulation. The decision was made to reuse the previous cannulation site at the right axillary artery. In the 1st patient, the side-graft technique enabled insertion of the EndoClamp, which made profound hypothermia unnecessary. In the 2nd patient, recannulation of the right axillary artery allowed us to open the sternum at low CPB flow using moderate hypothermia, since antegrade cerebral perfusion was easily accessible in the event of a more prolonged arrest time.
Re-dissection of the axillary artery should be performed meticulously and with minimal use of the cautery, to avoid neurologic injuries. The first objective of the dissection should be identification of the graft stump, which was easily accomplished in both of our patients. Subsequently, the axillary artery must be mobilized proximal and distal to the stump to enable safe proximal and distal clamping. The graft stump should be excised. The vascular lumen should be examined with care, since intimal hyperplasia induced by the graft may be present. Thereafter, a new graft is anastomosed to the axillary artery. We think that adopting such a methodical approach may reduce the risks of neurovascular complications, which may pose higher risk in a reoperative setting. Both patients in the present series were free of neurovascular and infectious complications.
Although the use of the contralateral undissected axillary artery or the femoral artery could have been contemplated in the present cases, we believe that recannulation of the right axillary artery is the best approach for such patients. Use of the left axillary artery does not allow the initiation of cerebral antegrade perfusion, and femoral cannulation significantly increases the risk of embolic complications and malperfusion in cases of aortic dissection.
Our experience as reported here suggests that re-use of the right axillary artery is safe and effective. This approach should be considered in patients previously cannulated in the right axillary artery who must undergo complex aortic reoperation, especially when the initiation of CPB before sternal opening is sought for safety reasons. Meticulous dissection with minimal use of the cautery reduces the risk of local neurovascular complications.