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1.  Right Axillary Artery Cannulation for Surgical Management of the Hostile Ascending Aorta 
Texas Heart Institute Journal  2005;32(2):189-193.
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 dissection, and is associated with fewer atheroembolic complications.
From September 2000 through March 2004, 27 patients underwent right axillary artery cannulation for acute ascending aortic dissection (n = 16), ascending aortic aneurysm (n = 9), or coronary artery bypass grafting (n = 2). Direct artery cannulation was performed in the first 4 patients, and the last 23 patients were cannulated through a longitudinal arteriotomy via an 8-mm woven Dacron graft. Seventeen patients underwent hypothermic circulatory arrest and antegrade cerebral perfusion.
Two patients died intraoperatively: one due to low cardiac output and one due to diffuse bleeding. One patient suffered mild right-arm paresthesia postoperatively, but recovered completely. Axillary artery cannulation was successful in all patients; it provided sufficient arterial flow, and there were no intraoperative problems with perfusion.
In the presence of extensive aortic or iliofemoral disease, arterial perfusion through the axillary artery is a safe and effective means of providing sufficient arterial inflow during cardiopulmonary bypass. In this regard, it is an excellent alternative to standard femoral artery cannulation.
PMCID: PMC1163468  PMID: 16107111
Aneurysm, dissecting/complications; aortic aneurysm/complications; arteriosclerosis/complications; axillary artery; cardiopulmonary bypass/methods; catheterization, peripheral/methods; extracorporeal circulation; femoral artery; reperfusion/methods; vascular surgical procedures
2.  Simplicity, skills, and pitfalls of ascending aortic cannulation for type A aortic dissection 
Background
Ascending aortic cannulation for an antegrade central perfusion during surgery for type A aortic dissection is simple and can be performed within median sternotomy. This cannulation is performed routinely without problems in our hospital. Using our experience, the skills and pitfalls were clarified to make this challenging procedure successful.
Methods
29 cases of ascending aortic cannulation using the Seldinger technique for insertion were studied. All insertions were performed with the guidance of transesophageal echocardiography alone. The cannulas were inserted after decompressing the aorta by initiating cardiopulmonary bypass with femoral artery cannulation. From our experience, the skills required for this procedure are the abilities to carefully assess the needle insertion site preoperatively, sense resistance to needle insertion twice, and ensure the guide wire is in the descending aorta and distal arch. The pitfalls are entrance of the guide wire into the false lumen and dilatation of the false lumen during the insertion procedure.
Results
There were no complications associated with ascending aortic cannulation. Regarding morbidity, 2 cases of brain infarction occurred. There were 3 hospital deaths unrelated to the procedure.
Conclusions
In surgery for type A aortic dissection, ascending aortic cannulation using the Seldinger technique is simple to perform. We found that some practical skills and precautions were required to make this procedure successful.
doi:10.1186/1749-8090-8-161
PMCID: PMC3699433  PMID: 23803285
Ascending aortic cannulation; Type A aortic dissection; Seldinger technique; Skills and pitfalls
3.  Mycotic Ascending Aortic Pseudoaneurysm Secondary to Pseudomonas Mediastinitis at the Aortic Cannulation Site 
Texas Heart Institute Journal  2003;30(4):322-324.
During the last 5 years, postoperative Pseudomonas mediastinitis has occurred in 2 of the 3,072 patients in our institution who have undergone cardiopulmonary bypass cardiac operations via a sternotomy. To our knowledge, there is no prior report in the English-language literature of postoperative Pseudomonas mediastinitis that originated at the aortic cannulation site, yet that was the site of origin in both of these patients.
The 1st patient developed a mycotic pseudoaneurysm of the ascending aorta at the cannulation site, secondary to the development of Pseudomonas mediastinitis following aortic valve replacement. This sequela was successfully treated by means of aneurysmectomy and closure of the aorta with a bovine pericardial patch, under cardiopulmonary bypass with circulatory arrest. The 2nd patient developed pseudoaneurysm and perforation of the aorta at the cardioplegia needle site, secondary to Pseudomonas mediastinitis following aortic and mitral valve replacement. This patient died. In both patients, the cannulation site and the cardioplegia needle site had been closed with pledgeted sutures. Pseudomonas aeruginosa was cultured from both sites.
Once the diagnosis of Pseudomonas mediastinitis is made following heart surgery, the patient should undergo reoperation, if possible, for removal of the foreign bodies (pledgeted sutures). In addition, these patients should be monitored with chest magnetic resonance angiography every 3 months for 1 year, in order to diagnose early development of a mycotic pseudoaneurysm and subsequent complications. (Tex Heart Inst J 2003;30:322–4)
PMCID: PMC307722  PMID: 14677747
Aneurysm, false; mediastinitis/prevention & control; Pseudomonas aeruginosa; pseudomonas infections; surgical wound infection/pathology
4.  Endovascular Repair of Descending Thoracic Aortic Aneurysm 
Executive Summary
Objective
To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA).
Clinical Need
Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition.
The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases.
The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia.
The Technology
Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs.
The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall.
The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration.
Review Strategy
Objectives
To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach
To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs
Measures of Effectiveness
Primary Outcome
Mortality rates (30-day and longer term)
Secondary Outcomes
Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation
Rate of reintervention (through surgical or endovascular approach)
Measures of Safety
Complications were categorized into 2 classes:
Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and
Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.
Inclusion Criteria
Studies comparing the clinical outcomes of ESG treatment with surgical approaches
Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs
Exclusion Criteria
Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta
Studies investigating the aneurysms of the ascending and the arch of the aorta
Studies using custom-made grafts
Literature Search
The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies.
One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria.
Summary of Findings
Mortality
The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).
Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.
Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.
Technical Success Rate
Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).
Surgical Reintervention
In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.
Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).
Endovascular Revision
In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.
Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.
Graft Migration
Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.
Aortic Rupture
In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.
Postprocedural Complications
In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.
Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).
Time-Related Outcomes
The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).
The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively.
Ontario-Based Economic Analysis
In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure.
Hospitalization Costs
The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative).
Professional (Ontario Health Insurance Plan) Costs
Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations.
The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes.
The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes.
Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured.
Conclusions
Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair.
There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention.
However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay.
PMCID: PMC3382300  PMID: 23074469
5.  Clinical Results of Ascending Aorta and Aortic Arch Replacement under Moderate Hypothermia with Right Brachial and Femoral Artery Perfusion 
Background
Selective antegrade perfusion via axillary artery cannulation along with circulatory arrest under deep hypothermia has became a recent trend for performing surgery on the ascending aorta and aortic arch and when direct aortic cannulation is not feasible. The authors of this study tried using moderate hypothermia with right brachial and femoral artery perfusion to complement the pitfalls of single axillary artery cannulation and deep hypothermia.
Materials and Methods
A retrospective analysis was performed on 36 patients who received ascending aorta or aortic arch replacement between July 2005 and May 2010. The adverse outcomes included operative mortality, permanent neurologic dysfunction and temporary neurologic dysfunction.
Results
Of these 36 patients, 32 (88%) were treated as emergencies. The mean age of the patients was 61.9 years (ranging from 29 to 79 years) and there were 19 males and 17 females. The principal diagnoses for the operation were acute type A aortic dissection (31, 86%) and aneurysmal disease without aortic dissection (5, 14%). The performed operations were ascending aorta replacement (9, 25%), ascending aorta and hemiarch replacement (13, 36%), ascending aorta and total arch replacement (13, 36%) and total arch replacement only (1, 3%). The mean cardiopulmonary bypass time was 209.4±85.1 minutes, and the circulatory arrest with selective antegrade perfusion time was 36.1±24.2 minutes. The lowest core temperature was 24±2.1℃. There were five deaths within 30 post-op days (mortality: 13.8%). Two patients (5.5%) had minor neurologic dysfunction and six patients, including three patients who had preoperative cerebral infarction or unconsciousness, had major neurologic dysfunction (16.6%).
Conclusion
When direct aortic cannulation is not feasible for ascending aorta and aortic arch replacement, the right brachial and femoral artery can be used as arterial perfusion routes with the patient under moderate hypothermia. This technique resulted in acceptable outcomes.
doi:10.5090/kjtcs.2011.44.3.215
PMCID: PMC3249305  PMID: 22263154
Aorta, surgery; Cardiopulmonary bypass; Cerebral protection; Hypothermia
6.  Liberal use of axillary artery cannulation for aortic and complex cardiac surgery 
OBJECTIVES
Axillary artery cannulation for cardiopulmonary bypass has been described previously as a safe and reliable technique, with a low risk of atheroemboli, avoidance of malperfusion in aortic dissection and facilitation of selective antegrade cerebral perfusion during hypothermic circulatory arrest. The aim of this study was to document the broad applicability of axillary cannulation and its associated morbidity and identify where it was not possible to use planned axillary cannulation.
METHODS
A retrospective review of a single surgeon's 10-year experience of axillary cannulation using the side-graft technique in 184 consecutive patients (age 22–92 years) in aortic and complex cardiac surgery from July 2002 to June 2012.
RESULTS
There were no intraoperative deaths and no major complications related to axillary artery use. There were six postoperative deaths unrelated to axillary artery cannulation. Six patients (3.3%) had minor complications as a direct result of axillary cannulation including seroma, haematoma, chronic pain and pectoralis major muscle atrophy. There were 10 cases where planned axillary cannulation was abandoned, due to inadequate size of the axillary artery in 8 patients and axillary artery dissection and morbid obesity in 1 patient each.
CONCLUSIONS
Axillary artery cannulation is an ideal arterial inflow site in cases where the ascending aorta is unsuitable as it is safe, reliable and reduces the risks of atheroembolization and malperfusion. Major complications are rare with this meticulous technique and it is our standard practice in complex cardiac and aortic surgery.
doi:10.1093/icvts/ivt056
PMCID: PMC3653471  PMID: 23456684
Axillary artery; Aneurysm; Dissection; Aortic aneurysm/surgery; Cardiopulmonary bypass/methods
7.  Central Cannulation by Seldinger Technique: A Reliable Method in Type A Aortic Dissection Repairs 
Background
Extensive type A aortic dissections that involve peripheral great vessels can complicate the choice of a cannulation site for cardiopulmonary bypass. We started to employ direct cannulation of the true lumen on the concavity of the aortic arch by Seldinger technique and evaluated the efficacy of this access technique as an alternative arterial inflow target in aortic surgery.
Material/Methods
Twenty-four consecutive patients (mean age: 59±14 years) underwent type A aortic dissection repair using selective antegrade cerebral perfusion. Direct aortic cannulation was used in 14 cases, subclavian access in 6 patients, and femoral entry in 4 patients. Perioperative factors were evaluated to identify the reliability and eventual benefits of direct cannulation method at the aortic arch.
Results
There were no operative deaths and cumulative 30-day mortality rate was 25% (6). Permanent neurological deficits were not observed; in 1 patient transient changes occurred (4%). Time to reach circulatory arrest was the shortest in the direct access group, with mean 27±11 (CI: 20.6–33.3) min vs. 43±22 (28.0–78.0) min (p=0.058) and 32±8 (23.6–40.4) min (p=0.34) by femoral cannulation and subclavian entry, respectively. Direct arch cannulation resulted in the best renal function in the first 72 h after surgery and similar characteristics were observed in lactic acid levels.
Conclusions
Ultrasound-guided direct cannulation on the concavity of the aortic arch using a Seldinger technique is a reliable method in dissection repairs. Prompt antegrade perfusion provides not only cerebral but also peripheral organ and tissue protection, which is an advantage in this high-risk group of patients.
doi:10.12659/MSM.890813
PMCID: PMC4251545  PMID: 25416498
Aortic Aneurysm; Aortic Diseases; Hemodynamics; Tissue Preservation
8.  Stanford type A aortic dissection. A new surgical approach. 
Texas Heart Institute Journal  1998;25(1):65-67.
We describe a new surgical technique adopted for the repair of Stanford type A aortic dissection. In order to minimize the risk of malperfusion caused by retrograde flow during cardiopulmonary bypass, we avoid femoral artery cannulation. On the hypothesis that it is best not to interfere with the hemodynamics of the dissection, we cannulate the dissected ascending aorta, in either the true or false lumen. We here report 2 cases of successful surgical treatment of Stanford type A aortic dissection. In both cases, the false lumen was cannulated under deep hypothermic circulatory arrest, without clamping the aorta. While the patient was cooling, a 10-mm GORE-TEX side arm was sutured to a Dacron graft prosthesis. Repair of the aortic arch was carried out 1st. The aortic cannula was inserted into the GORE-TEX side arm, the tubular prosthesis was cross-clamped, and cardiopulmonary bypass was reinstituted. After this, the aortic bulb was repaired as usual and the tubular prosthesis was sutured to the bulb. No postoperative cerebral complication occurred. Our experience must be confirmed by more cases and a longer follow up.
Images
PMCID: PMC325504  PMID: 9566066
9.  Total aortic arch replacement: current approach using the trifurcated graft technique 
Annals of Cardiothoracic Surgery  2013;2(3):347-352.
Since the pioneering work of DeBakey, Cooley, and colleagues more than 50 years ago, surgical treatment of aneurysms involving the transverse aortic arch has been associated with substantial morbidity and mortality. Over the past 15 years, techniques for replacing the diseased aortic arch have evolved substantially. Previously, our approach to these operations involved femoral cannulation, profound-to-deep hypothermic circulatory arrest and retrograde cerebral perfusion, and the island technique for reattaching the brachiocephalic vessels. In contrast, we currently use innominate artery cannulation, deep-to-moderate hypothermic circulatory arrest with antegrade cerebral perfusion, bilateral cerebral monitoring with near-infrared spectroscopy, and the trifurcated graft (Y-graft) technique for reattaching the arch branches. Cannulating the innominate artery to provide an inflow site for cardiopulmonary bypass has facilitated the use of antegrade cerebral perfusion as a cerebral protection strategy; the left common carotid artery is additionally perfused to provide bilateral cerebral perfusion. Despite having a systemic circulatory arrest time that often exceeds 60 minutes, these improved perfusion strategies make it possible to consistently avoid cerebral circulatory arrest all together. A moderate temperature target of between 18 and 23 °C is now used; this appears to reduce the risk of hypothermic coagulopathy and improve hemostasis. Y-graft techniques, such as the trifurcated graft approach, have the advantages of eliminating residual aortic arch tissue and being easily tailored to the needs of the individual patient. This report describes total aortic arch replacement in patients with aneurysms that are confined to the ascending aorta and transverse aortic arch.
doi:10.3978/j.issn.2225-319X.2013.05.02
PMCID: PMC3741858  PMID: 23977604
Aortic arch surgery; total arch replacement; trifurcated graft
10.  Cannulation in the Diseased Aorta 
Texas Heart Institute Journal  2006;33(3):353-355.
The Seldinger technique is a method of femoral cannulation that has been used to establish cardiopulmonary bypass. Reports of cannulation of the ascending aorta for antegrade perfusion using the Seldinger method are anecdotal. To the best of our knowledge, the approach described herein for direct cannulation of the ascending aorta with use of the Seldinger technique for antegrade perfusion has not been previously described in the English-language medical literature. This method is helpful when the surgeon is treating a patient who has a calcified ascending aorta, complicated aortic dissection, calcified femoral vessels, or a diseased thoracoabdominal aorta. In such cases, retrograde perfusion has been associated with severe complications as a result of atheromatous embolization from the descending thoracic aorta.
Herein, we describe our approach to cannulation for cardiopulmonary bypass, which entails insertion of an aortic cannula into the ascending aorta by means of the Seldinger technique. A soft-tip guidewire is inserted through an arterial entry catheter that has been used to puncture a hole in the wall of the vessel. Then the aortic cannula is introduced into the vessel, sliding along the guidewire. Guided by transesophageal echocardiography, the tip of the cannula is positioned carefully and is then advanced into the descending aorta. This positioning of the cannula decreases the chance of arterial embolization, thereby improving cerebral protection. If cannulation of the ascending aorta is not feasible, the transverse aortic arch or proximal descending aorta can be used.
PMCID: PMC1592270  PMID: 17041694
Aorta, thoracic; cardiopulmonary bypass/adverse effects/methods; catheterization/methods; cerebral protection; intraoperative complications
11.  Postoperative peri-axillary seroma following axillary artery cannulation for surgical treatment of acute type A aortic dissection 
The arterial cannulation site for optimal tissue perfusion and cerebral protection during cardiopulmonary bypass (CPB) for surgical treatment of acute type A aortic dissection remains controversial. Right axillary artery cannulation confers significant advantages, because it provides antegrade arterial perfusion during cardiopulmonary bypass, and allows continuous antegrade cerebral perfusion during hypothermic circulatory arrest, thereby minimizing global cerebral ischemia. However, right axillary artery cannulation has been associated with serious complications, including problems with systemic perfusion during cardiopulmonary bypass, problems with postoperative patency of the artery due to stenosis, thrombosis or dissection, and brachial plexus injury. We herein present the case of a 36-year-old Caucasian man with known Marfan syndrome and acute type A aortic dissection, who had direct right axillary artery cannulation for surgery of the ascending aorta. Postoperatively, the patient developed an axillary perigraft seroma. As this complication has, not, to our knowledge, been reported before in cardiothoracic surgery, we describe this unusual complication and discuss conservative and surgical treatment options.
doi:10.1186/1749-8090-5-43
PMCID: PMC2880968  PMID: 20500837
12.  Safety and efficacy of ascending aorta cannulation during repair of acute type A aortic dissection (PA29-04): “Presented at the 65th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery” 
Objective
Antegrade central perfusion for acute Stanford type A aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via the ascending aorta may improve surgical results of type A dissections, especially in situations of hemodynamic instability. Thus, we evaluated the safety and efficacy of cannulation of the dissected ascending aorta in acute type A dissection.
Methods
We reviewed the medical charts of patients undergoing repair of acute ascending aortic dissection (n = 52) from April 2010 to April 2013. Cannulation was accomplished in 29 patients via the ascending aorta (central) and in 23 patients via the femoral or axillary artery (peripheral). The ascending aorta was routinely cannulated using Seldinger technique under epiaortic ultrasound guidance. Comorbidities, mortality, complications, and durations of hospital stays were compared for the groups.
Results
In all cases, routine cannulation of the ascending aorta was safely performed with no resultant malperfusion or thromboembolism. Mean operative duration, cardiopulmonary bypass time, intubation time, and intensive care unit stay were significantly shorter in the central group. Two patients (6.8 %) in the central group died compared with four patients (17.3 %) in the peripheral group (P = 0.005).
Conclusions
Antegrade central perfusion via the ascending aorta, a simple and safe technique that enables rapid establishment of antegrade systemic perfusion, was as safe as peripheral cannulation in patients with type A acute aortic dissection.
doi:10.1007/s11748-013-0355-9
PMCID: PMC4004845  PMID: 24310294
Aortic dissection; Ascending aorta perfusion; Ultrasound
13.  Brachiocephalic Artery Cannulation in Proximal Aortic Surgery that Requires Circulatory Arrest 
Texas Heart Institute Journal  2014;41(6):596-600.
The brachiocephalic artery is an alternative cannulation site in the repair of ascending aortic lesions that require circulatory arrest. We evaluate the effectiveness and safety of this technique.
Proximal aortic surgery was performed in 32 patients from 2006 through 2012 via brachiocephalic artery cannulation and circulatory arrest. Twenty-four (75%) of the patients were men. The mean age was 48.69 ± 9.43 years (range, 30–68 yr). Twelve had type I dissection, 2 had type II dissection, and 18 had true aneurysms of the ascending aorta. All operations were performed through a median sternotomy. The arterial cannula was inserted through an 8-mm vascular graft anastomosed to the brachiocephalic artery in an end-to-side fashion. In dissections, the distal anastomosis was performed without clamping the aorta. The patients were cooled to 24 °C, and circulatory arrest was established. The brachiocephalic and left carotid arteries were clamped, and antegrade cerebral perfusion was started at a rate of 10 mL/kg/min. Cardiopulmonary bypass was resumed after completion of the distal anastomosis and the initiation of rewarming. The proximal anastomosis was then performed.
None of the patients sustained a major neurologic deficit, but 5 patients experienced transient postoperative agitation (<24 hr). There were 2 early deaths (6.25%), on the 3rd and the 11th postoperative days, both unrelated to the cannulation technique.
Brachiocephalic artery cannulation through a graft can be a safe and effective technique in proximal aortic surgical procedures that require circulatory arrest.
doi:10.14503/THIJ-13-3947
PMCID: PMC4251329  PMID: 25593522
Aneurysm, dissecting/surgery; aortic aneurysm, thoracic/surgery; brachiocephalic trunk; brain/blood supply; cannulation; cardiopulmonary bypass; catheterization/methods; circulatory arrest, deep hypothermic induced; heart arrest, induced; perfusion/methods; postoperative complications/prevention & control
14.  Repair of Coarctation-Related Aortic Arch Aneurysm and Ventricular Septal Defect in an Adolescent 
Texas Heart Institute Journal  2008;35(4):466-469.
A saccular aortic arch aneurysm that is secondary to aortic arch coarctation and that is accompanied by a ventricular septal defect is a rare combination in the adolescent patient. Total simultaneous repair of all of these conditions is desirable, because of the higher morbidity and mortality rates of staged procedures—particularly when resection of the saccular aneurysm is delayed.
Herein, we discuss the case of a 16-year-old boy who underwent simultaneous surgical correction of these malformations. With the aid of cardiopulmonary bypass on the beating heart, the coarctation and the aneurysmal segment were resected, and a tubular Dacron graft was interposed. The ascending aorta and femoral artery were both then cannulated to ensure whole-body perfusion during cardiopulmonary bypass. The ventricular septal defect was closed with the patient under cardioplegic arrest. After 10 days, he was discharged from the hospital without sequelae. We conclude that single-staged repair of cardiac abnormalities and of an aortic arch aneurysm that is secondary to coarctation of the aortic arch can be performed safely and effectively in adolescent and adult patients by use of our technique.
PMCID: PMC2607102  PMID: 19156244
Aorta/surgery; aortic aneurysm/physiopathology/surgery/ultrasonography; aortic coarctation/complications/physiopathology/surgery/ultrasonography; coronary disease/surgery; magnetic resonance angiography; methods; time factors
15.  Comparison of the Outcomes between Axillary and Femoral Artery Cannulation for Acute Type A Aortic Dissection 
Background
At present, many surgeons prefer axillary artery cannulation because it facilitates antegrade cerebral perfusion and may diminish the risk of cerebral embolization. However, axillary artery cannulation has not been established as a routine procedure because there is controversy about its clinical advantage.
Materials and Methods
We examined 111 patients diagnosed with acute type A aortic dissection between January 2000 and December 2009. The right axillary artery was cannulated in 58 patients (group A) and the femoral artery was cannulated in 53 (group F). The postoperative outcomes were retrospectively reviewed and compared between the two groups.
Results
There were 46 male and 65 female patients with a mean age of 58.9±13.1 years (range, 26 to 84 years). The extent of aortic replacement in both groups did not differ. There were 8 early deaths (7.2%) and 2 late deaths (1.8%). The mean follow-up duration was 46.0±32.6 months (range, 1 month to 10 years). Transient neurologic dysfunction was observed in 11 patients (19.0%) in group A and 14 patients (26.4%) in group F. A total of 11 patients (9.9%) suffered from a permanent neurologic dysfunction. Early and delayed stroke were observed in 6 patients (10.3%) and 2 patients (3.4%), respectively, in group A as well as 2 patients (3.8%) and 1 patient (1.9%), respectively, in group F. There were no statistical differences in the cannulation-related complications between both groups (3 in group A vs. 0 in group F).
Conclusion
There were no differences in postoperative neurologic outcomes and cannulation-related complications according to the cannulation sites. The cannulation site in an aortic dissection should be carefully chosen on a case-by-case basis. It is important to also pay attention to the possibility of intraoperative malperfusion syndrome occurring and the subsequent need to change the cannulation site.
doi:10.5090/kjtcs.2012.45.2.85
PMCID: PMC3322190  PMID: 22500277
Aorta, surgery; Axillary artery; Femoral artery; Cardiopulmonary bypass; Cannulation
16.  Assessment of Perfusion toward the Aortic Valve Using the New Dispersion Aortic Cannula during Coronary Artery Bypass Surgery 
Texas Heart Institute Journal  2000;27(4):361-365.
When there is an echocardiographic diagnosis of severe mobile atherosclerotic plaque in the aortic arch or descending aorta, perfusion toward the aortic arch during cardiopulmonary bypass may create a high risk of embolic neurologic injury. Other perfusion methods, such as cannulation of the femoral or axillary arteries, are not always possible, due to atherosclerosis. The ascending aorta may be an alternative site for perfusion, since it is less frequently diseased. We assessed a new technique of perfusion toward the aortic valve using a new cannula designed for this purpose (Dispersion aortic cannula).
Our study included 100 consecutive patients, 72 men and 28 women, with an average age of 68 ± 1.0 years (range, 39–89 years). There were no complications related to insertion of the cannula or perfusion. The ascending aorta could be cross-clamped and side-clamped without perfusion problems. Three deaths occurred; none was related to the cannulation technique. No intra-operative stroke occurred. Two patients suffered neurologic events, one on day 1 and the other on day 6; both had been fully alert after surgery. Perfusion toward the aortic valve appears to be safe and hemodynamically effective. This cannulation technique appears to be an acceptable alternative to present methods. Comparative studies will be needed to determine whether this alternative technique is effective in patients with severe aortic arch disease.
PMCID: PMC101105  PMID: 11198309
Aorta, thoracic/surgery; cardiac surgical procedures; cardiopulmonary bypass/methods; cerebrovascular accident/prevention and control; embolism, cholesterol/prevention and control; surgical instruments
17.  Complications of cannulation of the ascending aorta for open heart surgery 
Thorax  1970;25(5):604-607.
In a series of 420 ascending aortic cannulations for cardiopulmonary bypass, major complications occurred in three patients. Aortic dissection occurred in one patient believed to be due to aortic cross-clamping. Avoidance of this manœuvre is suggested when the aorta is grossly atheromatous. Two patients developing false aneurysms due to mediastinal infection are described. Prevention of mediastinal infection and its treatment are discussed. The method of treatment of false aneurysms by deep hypothermia is described.
Images
PMCID: PMC472196  PMID: 5489185
18.  Ascending aortic false aneurysm following cannulation for perfusion. 
Thorax  1976;31(2):234-237.
A case of false aneurysm originating from the ascending aortic cannulation site in the absence of mediastinal infection is described. Surgical treatment was carried out by means of limited cardiopulmonary bypass and hypothermic circulatory arrest, but the patient died early in the postoperative period. The technical failures responsible for the unsuccessful outcome are emphasized.
Images
PMCID: PMC470392  PMID: 941111
19.  Direct Cannulation of the Infrahepatic Vena Cava for Emergent Cardiopulmonary Bypass Support 
Texas Heart Institute Journal  2009;36(4):316-320.
Cannulation for cardiopulmonary bypass, although seemingly routine, can pose technical challenges. In patients undergoing repeat sternotomy, for example, peripherally established cardiopulmonary bypass may be necessary to ensure safe entry into the chest; however, establishing bypass in this way can sometimes be complicated by patients' body habitus. We describe a technique for direct cannulation of the infrahepatic abdominal vena cava that was required for emergent cardiopulmonary bypass. The patient was a 62-year-old woman who had presented with severely symptomatic left main coronary stenosis 3 months after elective aortic valve replacement. She had gone into cardiogenic shock as general anesthesia was being induced for repeat sternotomy and myocardial revascularization. Emergent establishment of femorofemoral cardiopulmonary bypass was precluded by difficulties in advancing the femoral venous cannula beyond the pelvic brim. Hence, an emergent celiotomy was performed, and the abdominal vena cava was directly cannulated to establish venous drainage for cardiopulmonary bypass. The rest of the operation was uneventful. Our technique for direct cannulation of the infrahepatic abdominal vena cava may be used in exceptional circumstances. Necessary precautions and potential pitfalls are also presented.
PMCID: PMC2720288  PMID: 19693306
Cardiopulmonary bypass/instrumentation/methods; shock, cardiogenic; vena cava, inferior
20.  Retrograde False Channel Perfusion 
The Annals of thoracic surgery  1970;9(3):263-266.
The current surgical treatment of dissecting thoracic aneurysms that originate above the aortic valve and dissect distally (Type I—De Bakey [3]) requires cardiopulmonary bypass for repair of the proximal intimal tear and obliteration of the false lumen [1, 2, 4, 5]. When the dissecting process extends toward the femoral arteries, cannulation of these vessels may result in perfusion of the false lumen. In addition, although a femoral cannula is inserted into the true lumen, perfusion of the false channel may occur through large reentry sites in the distal abdominal aorta or beyond the bifurcation. Retrograde arterial flow through the false lumen would jeopardize the blood flow to the central nervous system and to other vital organs. We have observed this complication in 2 patients with complete aortic dissection (Type I) during what appeared to be an otherwise adequate surgical procedure.
PMCID: PMC2978515  PMID: 5413750
21.  How I do it: transapical cannulation for acute type-A aortic dissection 
Aortic dissection is the most frequently diagnosed lethal disease of the aorta. Half of all patients with acute type-A aortic dissection die within 48 hours of presentation. There is still debate as to the optimal site of arterial cannulation for establishing cardiopulmonary bypass in patients with type-A aortic dissection.
Femoral artery cannulation with retrograde perfusion is the most common method but because of the risk of malperfusion of vital organs and atheroembolism related to it different sites such as the axillary artery, the innominate artery and the aortic arch are used. Cannulation of these sites is not without risks of atheroembolism, neurovascular complications and can be time consuming. Another yet to be popularised option is the transapical aortic cannulation (TAC) described in this article. TAC consists of the insertion of the arterial cannula through the apex of the left ventricle and the aortic valve to lie in the sinus of Valsalva. Trans-oesophageal guidance is necessary to ensure correct placement of the cannula.
TAC is an excellent method of establishing cardiopulmonary bypass as it is quick, provides a more physiological method of delivering antegrade arterial flow and is the only method to assure perfusion of the true lumen.
doi:10.1186/1749-8090-3-4
PMCID: PMC2248573  PMID: 18230144
22.  Painless Aortic Dissection Presenting as Paraplegia 
Texas Heart Institute Journal  2012;39(2):273-276.
Acute dissection of the aorta can be life-threatening. As a presenting manifestation of aortic dissection, neurologic complications such as paraplegia are rare.
Herein, we report the case of a 51-year-old man who presented with sudden-onset paraplegia and ischemia of the legs, with no chest or back pain. His medical history included coronary artery bypass grafting. Physical examination revealed pulseless lower extremities, and computed tomography showed aortic dissection from the ascending aorta to the common iliac arteries bilaterally. A lumbar catheter was inserted for cerebrospinal fluid drainage, and axillary arterial cannulation was established. With the use of cardiopulmonary bypass, the aortic dissection was corrected, and the previous coronary artery grafts were reattached. The surgery restored spinal and lower-extremity perfusion, and the patient walked unaided from the hospital upon his discharge 5 days later.
Although acute aortic dissection presenting as paraplegia is rare, it should be considered in patients who have pulseless femoral arteries bilaterally and sudden-onset paraplegia, despite no pain in the chest or back. Prompt diagnosis and intervention can prevent morbidity and death.
PMCID: PMC3384028  PMID: 22740752
Aneurysm, dissecting/complications/diagnosis/surgery; aortic aneurysm/complications/diagnosis/surgery; diagnosis, differential; extremities/blood supply; ischemia/complications; pain/physiopathology; paraplegia/etiology/physiopathology; spinal cord ischemia/etiology/surgery; treatment outcome
23.  “Open” approach to aortic arch aneurysm repair☆ 
Aortic arch aneurysm is a relatively rare entity in cardiac surgery. Repair of such aneurysms, either in isolation or combined with other cardiac procedures, remains a challenging task. The need to produce a relatively bloodless surgical field with circulatory arrest, while at the same time protecting the brain, is the hallmark of this challenge. However, a clear understanding of the topic allows a better and less morbid approach to such a complex surgery.
Literature has shown the advantage of selective cerebral perfusion techniques in comparison with only circulatory arrest. Ability to perfuse the brain has allowed circulatory arrest temperatures at moderate hypothermia without the need for deep hypothermia. Even though cannulation site selection appears to be a minor issue, literature has shown that the subclavian/axillary route has the best outcomes and that femoral cannulation should only be reserved for no access patients. Although different techniques for arch anastomosis have been described, we routinely perform the distal first technique as we find it to be less cumbersome and easiest to reproduce.
In this review our aim is to outline a systematic approach to aortic arch surgery. Starting with indications for intervention and proceeding with approaches on site of cannulation, approaches to brain protection with hypothermia and selective cerebral perfusion and finally surgical steps in performing the distal and arch vessels anastomosis.
doi:10.1016/j.jsha.2014.02.006
PMCID: PMC4062763  PMID: 24954988
Aortic arch aneurysm; Open repair; Hypothermic circulatory arrest; Selective cerebral perfusion; Distal first anastomosis
24.  Staged hybrid treatment of ascending aorta aneurysm post cardiac surgery 
We describe the management of ascending aorta aneurysm following a recurrent sternotomy wound infection in 2 male patients. The patients had undergone cardiac surgery using cardiopulmonary bypass with late complications of chronic sternal wound infection and saccular aneurysm at the aortic cannulation site. In both patients, following a multidisciplinary approach, a customized stent graft was implanted endovascularly into the ascending aorta to seal the aneurysm orifice followed by resternotomy, repair of the aneurysm and omentopexy. Both patients' postoperative course was uneventful.
doi:10.1093/icvts/ivt094
PMCID: PMC3653491  PMID: 23475117
Aortic operation; Aortic aneurysm; Endovascular procedures/stents; Sternotomy wound infection
25.  Bentall Operation with Valved Homograft Conduit 
Texas Heart Institute Journal  2000;27(4):366-368.
Lesions of the ascending aorta associated with aortic valve disease are usually treated by implanting a prosthetic valved conduit (Bentall procedure). In this report, we present our experience in which a valved homograft conduit was used for the procedure.
Six patients underwent a Bentall procedure with the use of a cryopreserved valved homograft conduit. Two of the patients had annuloaortic ectasia, 2 had Marfan syndrome, and 1 had an atherosclerotic aneurysm of the aorta. One patient had severe aortic stenosis due to a bicuspid aortic valve, along with an aneurysm and localized dissection of the ascending aorta. In all of the patients, the aortic annulus was substantially dilated, with accompanying moderate-to-severe aortic regurgitation. A standard procedure was performed with moderate hypothermia, cardiopulmonary bypass, and aortic and bicaval cannulation. The ascending aorta and the aortic valve were replaced with a cryopreserved valved homograft conduit (aortic in 5 patients and pulmonary in 1). The native coronary ostia were anastomosed directly to the homograft.
Echocardiography, which was performed intraoperatively, before discharge from the hospital, and at follow-up visits (1 to 36 months), revealed good valve function without dilatation of the homograft conduits. There was 1 late death due to Aspergillus fumigatus endocarditis, 6 months postoperatively. In 1 patient, magnetic resonance imaging performed at 24 months revealed normal caliber of the homograft conduit.
We conclude that the Bentall procedure can be performed, safely and with excellent results, using cryopreserved homograft conduits.
PMCID: PMC101106  PMID: 11198310
Aneurysm, dissecting; aortic valve/abnormalities; aortic valve/surgery; aortic valve insufficiency/surgery; Bentall operation; blood vessel prosthesis; Marfan syndrome/surgery; transplantation, homologous

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