Journal of Cardiothoracic Surgery - Latest Comments

Iatrogenic pseudoaneurysm of the axillary artery: Prevention better than cure.

Anand Sachithanandan — 2011-07-20T23:00:22Z

I read with interest the excellent report by Mazzaccaro et al regarding successful ultrasound guided endovascular stent repair of an iatrogenic axillary artery pseudoaneurysm via the brachial route (1). Although the reported incidence of iatrogenic axillary artery false aneurysms is rare, it is likely such complications will increase in the future as axillary cannulation becomes increasingly popular in contemporary surgical practice for repair of ascending aorta and arch aneurysms or dissections, and for re-operative procedures.
The advantages of axillary cannulation are numerous and includes continous antegrade perfusion, obviates the need to re-position the arterial cannula from the femoral site at a later stage in the operation, reduces the risk of false lumen malperfusion and eliminates retrograde extension of a dissection flap. Axillary cannulation also facilitates reliable selective antegrade cerebral perfusion (SACP) for complex cases requiring deep hypothermic circulatory arrest (DHCA). However, given the relative surgical inaccessibility of the infraclavicular proximal axillary artery, direct cannulation of this vessel may result in a higher chance of late post-operative pseudoaneurysm formation. Furthermore iatrogenic axillary stenosis with compromised antegrade brachial blood flow and brachial plexus injury are more likely to occur with a direct technique.
A simple but useful technique is to perform a side to end anastomosis with a small tubular vascular graft onto the axillary artery with partial heparinisation and use of a small partial occlusion side biting clamp. The graft can then be cannulated and subsequently decannulated with relative ease. At the end of the procedure, the graft can be simply ligated and divided, leaving a small residual stump. The safety and efficacy of this technique which avoids direct cannulation of the vessel is well validated (2).
References
1. Mazzaccaro D, Malacrida G, Occhiuto MT, Stegher S, Tealdi DG, Giovanni N. Journal of Cardiothoracic Surgery 2011, 6:78 Ann Thorac Surg.2010 Sep;90(3):731-7.

2. Wong DR, Coselli JS, Palmero L, Bozinovski J, Carter SA, Murariu D, LeMaire SA. Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections. Ann Thorac Surg. 2010 Sep;90(3):731-7.

The first two authors contributed equally the same to this study

Jan D. Schmitto — 2010-04-27T06:03:04Z

Please write in that article:

"The first two authors contributed equally the same to this study!"

Reservations on SAC

A Protopapas — 2008-08-29T05:59:37Z

Just a quick comment: cannulating the innominate artery does nothing to prevent cardiac injury upon re-entry, it just offers an option for the aortic pipe IN CASE OF CARDIAC INJURY-we still have to divide the sternum and mostly introduce bicaval cannulae.

I do not see how access for cannulation via the suprasternal notch is safer than redo sternotomy-the tissues are already adhered given the previous sternotomy, particularly where thymectomy and innominate cannulation have taken place in the first operation.The same applies to cavoatrial cannulation without sternotomy-a video showing the technique would be illuminating!

Kindest Regards

Aristotle D Protopapas MSc. FRCS

See a pubcast of this article at SciVee!

Lynn Fink — 2008-08-29T05:58:19Z

Link to a video of this article.

LAM is a real possibility

Ben Creagh-Brown — 2007-01-23T12:41:14Z

Dear Sirs,

I read your case with great interest. I have recent published a case of recurrent pneumothorax during pregnancy where the underlying diagnosis was LAM (Creagh-Brown B, Cooke N, Corbishley C, Conservative management of an unusual cause of breathlessness during pregnancy. Respiratory Medicine Extra (2006) 2, 116–119)

You mention the possibility that LAM may underlie your patient's presentations but do not explain what investigations have taken place to exclude this possibility. It would be reassuring to know that her pulmonary function tests and HRCT were normal.

Yours sincerely, Ben

Alternative single stage approach for dealing with CoA and associated cardiac disease.

jagannath byalal — 2006-07-28T06:53:29Z

I read with great interest the article detailing the use of sternotomy, TCA and extranatomic conduit for bypassing the coarcted segment. It indeed is an excellent palliation in the sense that it still uses a conduit, needs TCA which certainly is not totally benign and the conduit lie, position and length must be carefully adjusted so that compression by the cardiac mass does not occur.

We had a patient recently who was 50 yrs old, had severe calcific aortic stenosis and a very tight coarctation.

I elected to do both at a single sitting using a transverse sternotomy with a left thoracotomy extended onto the right side a little bit. In this particular instance I opened the right pleura but I believe that the same could be done without opening the pleura on the right side.

The access to the coarct segment was very good, I did a resection end to end anastomosis and followed with an aortic valve replacement in the usual fashion.

The patient did very well and is ready for discharge.

The only disadvantage is that the IMA on both sides may have to be sacrificed, however if concomitant grafting is needed then it can easily be harvested and used.

Moreover the access to the arch vessels is excellent and can be repaired .

So although the sternotomy approach with a extraanatomic graft may be a viable alternative I prefer to use the thoracotomy,transverse sternotomy approach.