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While graft cannulation of the axillary artery has become a standard approach for antegrade cerebral perfusion during aortic arch surgery, it is limited. The second incision can be morbid, with risk of injury to the brachial plexus. In addition, hyper-perfusion of the right upper extremity with a pressure gradient across the thoracic inlet is not uncommon, leading to spurious central pressure representation in a right radial artery. Graft cannulation of the innominate artery is an alternative to axillary cannulation that is done through the primary sternotomy incision. Graft cannulation is not associated with brachial artery injury, arm hyper-perfusion, or pressure gradients. The technique has been previously reported, and is documented to be safe and effective.
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Excellent idea to present this technique. Very clear and didactic video, Thank you very much. Two points:
1. Distal brachiocephalic trunk cannulation through a conduit is a great cannulation technique used often in pediatric cardiac surgery.
2. If peripheral arterial access is an issue, the Brachiocephalic trunk can be dissected and taped (or cannulated through a conduit) even in redo sternotomy cases, before the sternotomy is performed, through the very same skin incision (without extending it). The BCT is arising all most transversely, posterior and just inferior to the Jugular notch, as it is very clearly shown on your video. Its perivascular plane should be intact, even in redo cases because the previous surgeon usually, wouldn’t have been so far superiorly, and one can potentially put tapes around of it. Pre op CT is crucial in showing the planes and exact direction of the Trunk. George Belitsis, Senior Fellow, Royal Brompton and Harefield Hospitals, London. Thank you once again.
I’ve not thought it possible to expose the Innominant Artery for cannulation without initially performing sternotomy. Any exposure tricks would be apprciated. I do use this preferentially over Axillary Artery cannulation for arch surgery.
Dear Dr Clarke, thank you very much for your question. Even if the BCT cannulation is not our routine cannulation technique; we have smoothly identified and taped the BCT in an adult congenital patient with multiple sternotomies and poor peripheral vascular access, prior to sternotomy. Pre op CT imaging of the epi-aortic branches and the complete Circle of Willis is mandatory, combined with intraop NIRS use.
The midline skin incision should reach near to the sternal notch. After dividing the adipose tissue and the muscular layer, and before dividing the sternum, focus needs to be turned to the suprasternal area. Divide the interclavicular ligament (scar tissue if a redo, so you can increase mobility of the structures). Remaining in-between the two sternocleidomastoids go through the investing layer of the cervical fascia (along the skin incision direction and only for 20 mm superiorly to the sternal notch). Use a self retaining retractor (that an assistant needs to gently pull superiorly). Try to dissect posteriorly to the origin of the right sternocleidomastoid. The very distal BCT will be found there. Go around the vessel with a tape. If you try to follow it inferiorly and behind the manubrium (towards its origin) you will find out that is running rather transversely, and soon you can put a second tape around of it facilitating adequate exposure for further conduit anastomosis and cannulation. If it is a Redo sternotomy case, then again you need to identify the BCT behind the proximal right Sternocleidomastoid and dissect downwards so you can utilize the usually not scared perivascular space. The issue with the Redo case is that the scar tissue, will be conducting the pulse-vibration wave, so one should not use the pulsation as a guide, but only the anatomy and info from the pre op CT.
When CPB arterial return is to an epi-aortic branch (Carotids or BCT) using a conduit; we cut and flash them, before protamine is given; as we have witnessed once the conduit to be full of thrombus soon after protamine. The thrombus was almost extending in the carotid. If one needs to transfuse along protamine then central cannulation should be possible at this stage of the operation.
Thank you for your question and the opportunity offered, to share our limited, experience with BCT cannulation (prior to sternotomy). We believe that is a feasible way to cannulate if peripheral access is poor, even if it is not commonly used (just like the LV apical cannulation, is not commonly used but it can be very useful when needed). Congratulations again to Dr Sperling for the very educative video. George Belitsis, Senior Fellow in Harefield and Royal Brompton Hospitals, London.
Thank you very much. I may try the exposure electively before sternotomy in a non redo soon.
nicely displayed and narrated