Tips, Tricks, and Pitfalls for Cardiopulmonary Bypass

This video describes the set up and pitfalls for cardiopulmonary bypass, including common types of arterial and venous access, as well as cardioplegia routes and venting strategies.

For arterial access, aortic cannulation is the most common. First, epiaortic ultrasound is used to assess for aortic calcifications that would affect cross clamp and cannulation sites. Next, either the distal ascending aorta or the aortic arch is cannulated with initial placement of double purse string sutures, followed by aortotomy with an 11 or 15 blade scalpel.

After the cannula is in the aorta, it will fill retrograde with blood. Then it is connected to the arterial line, where the perfusionist checks for pulsatility and matching pressures. The perfusionist then gives some volume through the cannula to test for any resistance. Any problems in these steps could mean there is a kink in the cannula or, more concerningly, an aortic dissection.

Next, the first purse string suture is placed. This suture is placed with partial thickness through the aortic wall, usually done forehand, forehand, backhand, then either forehand or backhand. It is snared and the square configuration is noted.

The next purse string inversely mirrors the first one, where any place that the first suture is outside of the aorta, the second suture is within the aorta. This maximizes hemostasis and is often performed with both arms of the suture, using all forehand bites. The adventitia can hinder cannula placement, so clearing it from the aorta makes for smoother insertion.

Next, the aortotomy is created and the cannula and snare are inserted, ensuring that the snares are below any cannula markers. Other options for aortic cannulation include using the Seldinger technique, which is helpful during aortic dissections, and the “stab and go” technique.

For “stab and go,” assistance is crucial since it is performed when the patient is crashing and no purse strings are used, so the cannulae can easily dislodge. Quickly, an aortotomy is created and a cannula is placed and connected to the lines. A right atriotomy and venous cannula are placed, connected, and bypass is initiated.

Pitfalls in aortic cannulation include difficulty with cannula insertion, which is usually due to the aortic adventitia obstructing the aortotomy, or the aortotomy being too small. Prior to connecting the lines, deairing is critical to prevent air emboli. A calcified aorta may result in stroke during cannulation, so epiaortic ultrasound can help guide cannula placement.

Lastly, iatrogenic aortic dissection occurs uncommonly, but must always be considered a possibility during cannulation due to its repercussions. Besides the earlier mentioned checklist, prevention includes cannulating the aorta when SBP is under 110 mmHg.

Axillary artery cannulation is most commonly used during circulatory arrest operations due to the ability to provide antegrade cerebral perfusion and avoidance of the aorta. With this technique, blood pressure monitoring is needed in both the right and left arms to assess for hyper and hypoperfusion.

The two options for cannulation are direct insertion or anastomosing a side graft, usually 8 or 10mm in diameter. First, the anatomical borders are marked: deltoid, mid third of the clavicle, and lateral edge of the sternum. A 4 cm incision is made infraclavicularly at the mid third of the clavicle, then dissected and spread with retractors.

The pectoralis major is divided, but the pectoralis minor can often be retracted inferiorly. Surgeons then palpate for the arterial pulse and use sharp and blunt dissection to locate the subclavian vein, in which a vessel loop is then used to retract inferiorly. Afterwards, the artery is noted, and vessel loops are placed for proximal and distal control.

For the direct insertion technique, a double purse string is placed in a similar fashion to the aortic cannulation using partial thickness bites, then the adventitia is cleared. Pitfalls for axillary cannulation include brachial plexus injury, axillary artery dissection, and postoperative seroma formation.

Femoral artery cannulation is useful for redo sternotomy cases, as well as for obtaining emergent arterial access. Direct insertion via groin cutdown or percutaneous Seldinger technique is most commonly performed. Anastomosis of a side arm graft is an option, but more frequently performed for ECMO.

Pitfalls include femoral artery dissection, a slightly higher stroke risk than aortic cannulation, and groin cutdown infections. Peripheral arterial disease is a particular concern with femoral cannulation. Whether there are severe femoral calcifications, stenotic lesions, or aneurysmal disease, they can all be very problematic with femoral bypass due to ischemia, stroke risk, or aneurysmal rupture.

Transapical cannulation is often a last resort when the aorta is not an option, such as during a Type A dissection with rupture. A ventriculotomy is created, watching out for the LAD, and the cannula is inserted into the ventricle then through the aortic valve. Another option in this situation could be the Samurai technique, in which the aorta is transected, the cannula is directly placed, and a cross clamp is applied. This results in a brief period of warm circulatory arrest.

For venous cannulation, right atrial cannulation with a double or triple stage cannula is most commonly used. The cannula can be placed in two locations: the right atrial appendage, which is easier to close during decannulation, but the pectinate muscles here may hinder initial cannula insertion; and the free wall of the right atrium, which has thinner pectinate muscle, making cannula insertion easier. However, the thinner wall makes bleeding more likely during decannulation.

For either approach, a single purse string is placed followed by atriotomy with an 11 blade, dilated with a tonsil, and a cannula is inserted with the distal tip sitting in the IVC, just past the hepatic vein. The purse string is placed with a double loaded suture, usually forehand for a few bites, followed by another few bites forehand or sometimes backhand. The atriotomy is created, dilated, and the cannula is inserted.

The cannula has two marking lines to help assess depth during placement. A simplified guide, based on average height, is to place the cannula to the first marker for females and to the second marker for males. The cannula is snared and connected to the venous line and the patient is ready to initiate bypass.

Pitfalls for atrial cannulation include difficulty inserting the cannula, which is usually due to the pectinate muscles. Poor venous drainage can be due to a number of factors, such as hypovolemia and cannula depth. A cannula that is too superficially placed can cause poor IVC drainage and if it is placed too deep, can cause poor SVC drainage. Hepatic congestion can occur when the distal tip of the cannula is lodged in the hepatic vein. Echocardiogram guidance can help prevent this complication.

Lastly, injury can occur to the SA node if the purse string is placed too close to the cavoatrial junction, and right coronary artery injury can occur if the purse string is placed too close to the atrioventricular junction.

Bicaval cannulation is used commonly for right-sided surgeries such as tricuspid, pulmonic, and atrial septal and ventricular septal surgery, but is also helpful in mitral valve surgery. The cannulae can be placed directly into the SVC and IVC, or it can be placed in the right atrium and guided into the SVC and IVC. For direct placement into the SVC and IVC, taking down the pericardial reflections here can help with exposure, but be aware that this will also weaken the walls of the cava, making tears more likely.

For SVC cannulation, sharp dissection of the pericardial reflection is preferred since cautery may cause thermal injury to the phrenic nerve. A single purse string is placed, full thickness, double loaded, backhand, forehand, forehand, then backhand again with the other arm. Surgeons are mindful to avoid any central line or swan ganz catheter that could easily be caught with this suture.
An 11 blade is then used to open the cava, it is dilated, then the cannula is placed and snared. These cannulae usually have markers which should be monitored when connecting the lines to ensure the cannula tip remains pointing in the correct direction, since it is possible for the tip to flip into the right atrium during adjustments.

IVC cannulation is performed in a similar manner. The purse string is placed, followed by an 11 blade for caval opening, and then cannula placement. Again, the cannula markings keep the tip in the right direction.

Pitfalls for bicaval cannulation include poor venous drainage, which is often due to the cannula being too deep. SVC and IVC stenosis can occur when the purse string is too wide, narrowing the caval diameter after decannulation. Patch repair may be needed to fix this issue. SA nodal injury can occur when the cannula is placed too close to the cavoatrial junction, and phrenic nerve injury can occur during takedown of the SVC pericardial reflections.

The IVC can have fragile tissue which tears easily and, at times, can tear even more with repair sutures. Very careful suture placement here is key, but in extreme cases, a patch repair may be necessary.

Femoral venous cannulation is useful in redo sternotomies and needed for emergent venous access. Groin cutdown or percutaneous Seldinger technique are used for placement. It is important to be mindful of iliac vein perforation, which may occur if the cannula is placed without a guidewire. Distal venous thrombosis is uncommon due to heparin, but groin site infections can occur more frequently, usually due to the cutdown technique.

After cannulation, cardioplegia access is the next step. Antegrade cardioplegia is very common, with the cannula placed in the aortic root or ascending aorta. However, it is important to be wary of its use in patients with aortic regurgitation as well as severe coronary artery disease.

Monitoring of the cardioplegia is performed by directly palpating the aorta, feeling the distension and pressure, as well as being monitored by the perfusionists. They watch the backpressure on the cardioplegia line. It is also important to check that the catheter is placed completely within the aorta since partial placement could result in an aortic dissection.

Next, a single horizontal mattress suture is placed, followed by the cannula. These cannulae may have a Y configuration in which one arm is for cardioplegia and the other for aortic root venting. Retrograde cardioplegia is useful in patients with aortic regurgitation, severe coronary disease, and those undergoing mitral surgery. It is place through the free wall of the right atrium, or if bicavally cannulated, the right atrium can be opened and the cannula can be placed directly inside the coronary sinus.

Monitoring of retrograde cardioplegia is twofold. The pressure tubing within the catheter provides direct monitoring of the coronary sinus pressure, and the cardioplegia line backpressure is monitored by the perfusionists.

Coronary sinus injuries do occur and are usually precipitated by aggressive placement of the cannula in frail patients. A large pericardial patch is used to fix these injuries. A simple purse string is placed, followed by atriotomy with an 11 blade, dilation, and a cannula entry. One trick for cannula placement is to aim the cannula first down the IVC, then slowly bring it up and into the coronary sinus, aiming left then up to the left shoulder.

Blood should immediately fill the cannula once it enters the coronary sinus. With the trocar removed, the very dark blood should continue to exit the proximal cannula. Coronary sinus pressure is higher than CVP, so if the cannula is misplaced into the right atrium, this event will not occur.

Next, surgeons attach the retrograde pressure line and watch the readings. The pressure should be similar to the right ventricular pressure. A too deep catheter will show pressure similar to left ventricular pressure, and a cannula in the right atrium will show the CVP.

Handheld cardioplegia can be given directly into the coronary ostia whenever the aorta is opened. The perfusionists monitor the cardioplegia line backpressure to ensure adequate flow. Surgeons should be mindful in patients with a short left main coronary artery since the cannula may directly enter only the LAD or circumflex artery, leaving the other one ischemic.

Venting options for the heart include aortic root venting and left ventricular venting. The root vent can be either a specified cannula, such as the antegrade cardioplegia cannula, or a large bore angiocatheter. The left ventricular vent options include entry from the right superior pulmonary vein and past the mitral valve, the left ventricular apex, or via indirect venting from the main pulmonary artery. For right superior pulmonary vein vent placement, a purse string is made, then opened and dilated, followed by placement of the vent past the mitral valve into the ventricle.

The principle for decannulation is the same for all sites. The cannulae are removed, the snares tighten the purse strings, then the purse strings are tied. For the right atrial appendage, a clamp can be placed on the tip and a silk suture tied just below. SVC and IVC decannulation follow similar patterns with cannula removal, snare tightening, and tying.

References

1. Moschovas, A., Amorim, P. A., Nold, M., Faerber, G., Diab, M., Buenger, T., & Doenst, T. (2017). Percutaneous cannulation for cardiopulmonary bypass in minimally invasive surgery is associated with reduced groin complications. Interactive cardiovascular and thoracic surgery, 25(3), 377–383. https://doi.org/10.1093/icvts/ivx140
2. Modi, P., & Chitwood, W. R., Jr (2013). Retrograde femoral arterial perfusion and stroke risk during minimally invasive mitral valve surgery: is there cause for concern?. Annals of cardiothoracic surgery, 2(6), E1. https://doi.org/10.3978/j.issn.2225-319X.2013.11.13
3. Bedeir, K., Reardon, M., Ramchandani, M., Singh, K., & Ramlawi, B. (2015). Elevated Stroke Risk Associated With Femoral Artery Cannulation During Mitral Valve Surgery. Seminars in thoracic and cardiovascular surgery, 27(2), 97–103. https://doi.org/10.1053/j.semtcvs.2015.06.008
4. Wong, D. R., Coselli, J. S., Palmero, L., Bozinovski, J., Carter, S. A., Murariu, D., & LeMaire, S. A. (2010). Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections. The Annals of thoracic surgery, 90(3), 731–737. https://doi.org/10.1016/j.athoracsur.2010.04.059
5. Pruna-Guillen, R., Ascaso, M., Affronti, A., Quintana, E., Sandoval Martínez, E., & Pereda, D. (2021). Direct true lumen cannulation for type A aortic dissection (Samurai technique) in emergency scenarios. Multimedia manual of cardiothoracic surgery : MMCTS, 2021, 10.1510/mmcts.2021.073. https://doi.org/10.1510/mmcts.2021.073

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.