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For establishing regular cardiopulmonary bypass, the ascending aorta is obviously the standard site of arterial cannulation, ensuring adequate blood supply to the whole body. However, when the aortic arch has to be replaced, finding a suitable arterial cannulation site becomes more challenging.
The femoral artery is an answer to this situation, and for a long period of time its cannulation was established as a routine practice. However, in a small number of patients, particularly those with aortic dissection, fatal complications like atheroembolism, malperfusion, ischemic complications, and even aortic rupture have been encountered. Moreover, total circulatory arrest is usually necessary during surgical correction involving the distal ascending aorta and the arch of the aorta. Unfortunately, systemic hypothermia and external cranial cooling alone cannot ensure adequate cerebral protection. Cerebral perfusion, preferably antegrade flow, along with hypothermia is a well-accepted and practiced technique, but requires some time to set up, mandating an interruption of cerebral blood flow. Therefore, identifying a suitable alternative site that can provide antegrade blood flow to the whole body, as well as maintaining cerebral perfusion, even at the time of arch exclusion or repair, is necessary.
Right axillary artery cannulation is practiced, but the procedure is time-consuming, with an increased risk of injury to neighboring structures, and it has limited efficiency of perfusion due to the artery’s narrow caliber. Use of the brachiocephalic artery ensures better perfusion, but has the risk of being involved in the arch pathology, which makes it prone to malperfusion and embolization.
In contrast, the common carotid artery is a potential alternative. It can be approached easily with a minimum risk of collateral injury due to its superficial anatomical location, and it is bilaterally available. It can provide antegrade blood flow to the entire body, and can also maintain cerebral perfusion during circulatory arrest without any interruption.
In this video, the authors demonstrate the procedure of cannulation of the right common carotid artery. The patient was a 17-year-old girl with a history of ventricular septal defect closure and patent ductus arteriosus ligation done 10 years previously. She presented with acute type A aortic dissection. Her right subclavian and right common carotid artery both were directly originating from the arch of the aorta. The right common carotid artery was the ideal option for arterial cannulation.
A 4 cm skin incision was made in the neck, along the medial border of the sternocleidomastoid muscle and 2 cm above its sternal insertion, extending toward the ear lobe. A self-retaining retractor was applied, the platysma muscle was dissected, and the right jugular vein was exposed just below the muscle. The vagus nerve was easily identified between the common carotid artery and the jugular vein. The right common carotid artery was dissected, and a vascular loop was passed around it. A side-biting clamp was placed, and an arteriotomy was created. A 10 mm vascular prosthesis was anastomosed end-to-side to the artery with a continuous 5.0 Prolene suture. The other end of the vascular prosthesis was tied to a connector and then attached to the arterial perfusion line. Venous cannulation was accomplished through the femoral vein.
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3 Comments
This is a cannulation option not often considered. Another very nice use of it is in complex aortic cases such as a pseudoaneurysm requiring circulatory arrest on sternal re-entry to provide ACP. A 12F cannula can be used with a separate line from the BPB circuit and continuous cold blood provided to the brain while the aortic situation is sorted out.
Thank you for the video.
The use of Carotid artery cannulation has been used in a few occasions with conduit. Even bilateral cannulation. Carotid cannulation is the way to cannulate neonatal ECLS (obviously no conduit).
I do congratulate you for bringing up this very very interesting topic.
In the setting You are describing, the incision can be longitudinal anterior to the SCM or even limited transverse incision on the skin and longitudinal on the investing layer of the deep cervical fascia, anterior to the SCM.
NIRS need to be used bilaterally.
Use proximal and distal 1200 clamps and after limited arteriotomy, release distal clamp to check if back flow from the head is enough (unless you have imaging of circle of Willis pre op, confirming completeness).
Additionally, there is always the risk of overflowing the brain as the total CPB flow will go into this single carotid vessel (I do appreciate that majority of the flow goes to the lower body). Make sure that the venous drainage is adequate from the head. I think NIRS are important. In my experience we have cannulated with conduits both carotids for a setting of arch surgery (Brompton Hospital with Dr Ulrich Rosendahl).
Remove the conduit from the carotid artery before protamine is given. I have witnessed that even soon after protamine administration, clot occurs in the conduit, that extends into the carotid. Make sure you allow the carotid to back and forward bleed free, before reconstructing. Consider reconstructing the longitudinal arteriotomy with patch and consider short term anticoagulation according to your local protocol.
Three remarks:
1. One can cannulate the Subclavian artery as it exits the clavicle (at the medial 1/3 of the clavicle). The brachial plexus is not in danger at that point, because it still consists of trunks that are all superiorly to the artery (have just exit the scalene hiatus).
2. Even though not suitable for AAD surgery setting, I have dissected free the Brachiocephalic artery, prior to multiple redo sternotomy, in a case of poor peripheral access. This way in case of injury, the Brachiocephalic artery could be cannulated directly, with a 16Fr paediatric cannula (depending on the site of injury, you direct the cannula to the head or the arch). Comments by me, on how to access the BCT prior to redo sternotomy, can be found at the comments section of, another brilliant video by Dr Jason Sperling on CTSnet July 13th 2015 : https://www.ctsnet.org/article/innominate-artery-graft-cannulation-aortic-arch-surgery
3. Never forget that the LV apex, is an alternative way to cannulate prior to multiple sternotomy (or even AAD), via a limited anterior thoracotomy.
4. I have seen carotid artery cannulation, with conduit, in a paediatric patients that are referred to us being on ecmo support already. I recall a case, that it was not bleeding, it had a stable ecmo run, but when it was weaned successfully from ecmo and decannulated, a very large INTRAMURAL hematoma of the Common carotid artery distal to the cannulation was there. The artery was reconstructed.
With your video you gave the chance of discussion and you reminded all, of a good way to cannulate. Thank you very much, and congratulations.
Thanks for the comments. Here the situation was very unique. Redo situation with acute type A aortic dissection.
Her right subclavian and right common carotid artery both were directly originating from the arch of the aorta. Axillary cannulation was not helpful for ACP. The right common carotid artery was the ideal option for her arterial cannulation.