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Background: Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD)., Methods: The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral., Results: The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia., Conclusions: Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach., Methods: A total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography., Results: The rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2., Conclusions: Most strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The site of arterial cannulation is an important consideration in the prevention of cerebral infarction after total arch replacement. We compared the outcomes of cannulation of the bilateral axillary artery, the femoral artery, and central cannulation in total arch replacement., Methods: Enrolled were 242 patients, categorized into three groups according to the arterial cannulation site used: bilateral axillary artery group, 124 patients; femoral artery group, 88 patients; central cannulation group, 30 patients. Selective cerebral perfusion was used for brain protection in all patients. Surgical outcomes, including the incidence of postoperative cerebral infarction, were compared between the groups., Results: Cardiopulmonary bypass time and lower-body circulatory arrest time were significantly shorter in the bilateral axillary artery group. Frozen elephant trunk procedure was performed in 54% of the bilateral axillary artery group (P < .001), and concomitant coronary artery bypass graft surgery was performed in 40% of the central cannulation group (P < .01). Hospital mortality in the bilateral axillary artery group was 1.6%, compared with 1.1% in the femoral artery group, and 0% in the central cannulation group (P = .72). The incidence of permanent neurologic deficit was significantly lower in the bilateral axillary artery group (0.8%) than in the central cannulation group (13%; P = .02). Logistic regression analysis indicated that bilateral axillary artery perfusion was a significant factor in the prevention of permanent neurologic deficit (odds ratio 0.10, P = .03)., Conclusions: Recent technical advances using bilateral axillary artery perfusion and frozen elephant trunk technique were associated with shortening cardiopulmonary bypass time and prevention of postoperative cerebral infarction in total arch replacement., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study seeks to assess the outcomes of direct axillary artery (AX) cannulation for thoracic aortic surgery., Methods: From October 2009 to November 2021 direct AX cannulation was planned in 515 patients for thoracic aortic pathology. An important aspect of our technique is that the cannula is not inserted deeper than 3 cm. AX cannulation-related events included shift of cannulation site from the initial site, vascular injury, and iatrogenic dissection., Results: Half of the patients had acute type A dissection (ATAD). An angled cannula was used in 442 patients and a straight cannula in 73 patients (14.2%) after August 2020. A previously cannulated AX was reused in 36 patients (7.0%). Mortality and stroke rates were 5.4% (ATAD vs non-ATAD: 8.0% vs 2.8%, P = .008) and 2.7% (ATAD vs non-ATAD: 4.6% vs 0.8%, P = .034), respectively. AX cannulation-related events were observed in 2.7% of patients. There was no difference in the vascular injury rate between ATAD and non-ATAD cases (1.6% vs 0.4%, respectively; P = .385), between different cannula types (angled vs straight: 0.9% vs 1.4%, P = 1.00), or between primary and redo AX cannulation cases (0.8% vs 2.8%, respectively; P = .791). On multidetector computed tomography analysis using automated 3-dimensional images, the mean distance from the thoracoacromial artery to the vertebral artery on the right and left sides was 8.70 cm and 8.69 cm, respectively., Conclusions: Direct AX cannulation for thoracic aortic repair is safe and carries a low rate of vascular injury, especially in elective cases. Our direct cannulation technique, which includes not inserting a cannula deeper than 3 cm, seems to be safe in not occluding the vertebral artery., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Femoral and axillary cannulation for arterial inflow in acute type A aortic dissection are the most commonly used cannulation strategies in current practice. More recently, our group and others have successfully used a central cannulation technique with excellent results. Although this approach has been described, specific technical details have not been clearly defined. In addition, the ideal anatomic characteristics of different types of aortic dissections amenable to central cannulation have not been delineated. The purpose of this brief communication is to describe the technical and procedural details specific to cannulation of the dissected ascending aorta and to propose a classification scheme of ascending aortic dissection anatomy based on difficulty of central cannulation. [ABSTRACT FROM AUTHOR]

Background: Several techniques are available for aortic arch replacement. We evaluated our experience with total aortic arch replacement using a presewn multibranched graft and right axillary artery cannulation for brain perfusion. Methods: Between 2002 and 2010, 88 patients (mean age, 61.5 ± 14.6 years) underwent total aortic arch replacement by midline sternotomy (27 patients) or bilateral anterior thoracotomy (61 patients). During a brief period of deep hypothermic circulatory arrest (DHCA) (mean duration, 11.0 ± 7.8 minutes), the brachiocephalic arteries were detached from the aorta and clamped. Cerebral perfusion through the right axillary artery was then initiated while the arteries were sequentially attached to the branches of the presewn graft (mean duration: 40.4 ± 9.8 minutes). The ascending aorta and entire arch were replaced in all patients, combined with varying lengths of the descending aorta. Results: The 30-day mortality rate was 5.7%. Stroke occurred in 3.4%, spinal cord ischemic injury in 3.4% (1 paraplegia, 2 paraparesis), and new-onset renal failure requiring dialysis in 3.4% of patients. The 5-year survival rate was 70.7% ± 5.5%. All graft branches remained patent during imaging follow-up (mean duration, 2.6 ± 2.2 years). Six patients required reoperation on the graft or contiguous aorta after the initial repair, but no reoperations were required on the aortic arch or its branches. The 5-year rate of freedom from reoperation was 90.4% ± 4.0%. Conclusions: The use of a presewn multibranched graft and hypothermic brain perfusion through the right axillary artery is a safe method for replacement of the aortic arch, resulting in a low incidence of neurologic complications and favorable durability and patency. [ABSTRACT FROM AUTHOR]

Background: This study assessed the safety of direct axillary artery (AX) cannulation for acute type A dissection (ATAD) repair, including the impact of innominate artery dissection (IAD)., Methods: Of 281 consecutive patients who underwent ATAD repair from 2007 to 2020, preoperative computed tomography was available in 200 (IAD, n = 101; non-IAD, n = 99). IAD with compromised true lumen was defined as dissection in which the false lumen was greater than 50% of the IA diameter (n = 75 of 101)., Results: AX cannulation was attempted in 188 patients (94.0%), with a 1.6% vascular injury rate (3 patients), comprising bypass to the distal AX in 2 patients and local dissection in 1 patient. Deep hypothermic circulatory arrest was used for the distal repair in 89.5% of patients. Right AX cannulation was used in 80.2% of patients with IAD and in 88.9% without IAD (P = .075). Patients with IAD had more cerebral (21.8% vs 5.1%, P = .001) and arm malperfsion (11.9% vs 4.0%, P = .075). Operative death and stroke were comparable between non-IAD (8.1% vs 7.9%, P = 1.00) and IAD (4.0% vs 5.3%, P = .689) groups. The right AX was successfully used in 77.3% of IAD patients with a compromised true lumen, with comparable hospital outcomes to noncompromised IAD patients. Upper extremity malperfusion, multiorgan malperfusion, low ejection fraction, and female sex were predictors for noncannulation of the right AX., Conclusions: Routine direct AX cannulation strategy is safe in ATAD repair. Right AX cannulation can be used in most patients with IAD, even with a compromised true lumen, with low mortality, stroke, and vascular injury rates., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The axillary artery can be cannulated for antegrade cerebral perfusion directly or by employing a prosthetic vascular graft anastomosed to the artery., Methods: From 2008 until 2019, 688 patients underwent axillary artery cannulation. Of those, 287 underwent direct cannulation and 401 cannulation through a side graft. We identified risk factors for cannulation-related complications, and after propensity score matching, we compared the 2 matched cohorts' cannulation-related and postoperative outcomes., Results: A smaller axillary-artery diameter (odds ratio = 0.70; 95% confidence interval, 0.56-0.87) and emergency surgery (odds ratio = 2.23; 95% confidence interval, 1.27-3.92) were identified as risk factors for cannulation-associated complications. In the propensity score-matched cohorts (n = 266 in each), the number of patients experiencing cannulation-related complications was significantly higher in the direct cannulation group than in the side-graft group (n = 33 [12.4%] versus n = 15 [5.6%]; P = .01). The direct group's incidence of iatrogenic axillary artery dissection was significantly higher (n = 17 [6.4%] versus n = 4 [1.5%] P = .008); their incidence of postoperative stroke was also significantly higher (n = 39 [14.7%] versus n = 21 [7.9%]; P = .025). Patients cannulated with a side graft needed more transfusions of blood products (median [IQR]: 3.0 [1.0-6.0] versus 4.0 [2.0-7.0;] P = .009)., Conclusions: Cannulating the right axillary through a vascular prosthetic graft reduces cannulation-related complications such as iatrogenic axillary artery dissection and lowers stroke rates. To help prevent cannulation-related complications and stroke, we recommend the routine use of a side graft when cannulating the axillary artery., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A patient with Marfan syndrome who had previously undergone a Cabrol procedure and thoracoabdominal aortic replacement had enlarging, symptomatic aneurysms in the subclavian-axillary artery and aortic arch. Both vessels were replaced with prosthetic grafts. A thoracic endoprosthesis was inserted bridging the aortic arch graft and the previously implanted descending aorta graft. Another stent graft was placed, bridging the axillary artery and a branch of the aortic arch graft. All the stent graft landing zones were within grafts, avoiding contact between the endoprostheses and fragile aortic wall. The aneurysms were excluded from the circulation, and the patient had no serious complications. [Copyright &y& Elsevier]

Extracorporeal membrane oxygenation (ECMO) has become a widely accepted short-term mechanical circulatory support device in patients with refractory cardiogenic shock. A major drawback of the peripheral venoarterial extracorporeal membrane oxygenation is that in patients with profoundly reduced left ventricular contractility associated with high left-heart filling pressure, there is always concern for venting the failing ventricle. We describe a minimally invasive technique for decompressing the left ventricle in this setting using a novel pulsatile paracorporeal assist device, the iVAC 3L (PulseCath, Groningen, The Netherlands). It is implanted through the right axillary artery and provides hemodynamic support while directly off-loading the left ventricle. [Copyright &y& Elsevier]

Background: The axillary intraaortic balloon pump (IABP) is frequently used in selected patients for circulatory support as a bridge to heart transplantation. The purpose of this study was to investigate the safety and efficacy of axillary intraaortic balloon pump (IABP) support for heart transplant candidates., Methods: The study investigators collected data on 133 patients who underwent axillary IABP support as a bridge to transplantation from July 2009 to April 2019. Of these patients, 94 (70.7%) underwent IABP insertion with surgical axillary grafts, and 39 (29.3%) underwent percutaneous IABP insertion. The outcomes of interest included ambulatory data, IABP-related complications, and successful heart transplantation with this type of support., Results: The overall preoperative ejection fraction was 20.3% ± 8.0%. The median duration of axillary IABP support was 21days, with 131patients (98.5%) mobilizing with the device. Hemodynamic variables significantly improved after the axillary IABP support was placed. Overall, 122 patients (91.7%) were successfully bridged to heart transplantation. Six patients (4.5%) required escalation to further mechanical support. Two patients (1.5%) died while awaiting transplantation. Four patients (3.0%) experienced a stroke during axillary IABP support (3 before transplantation and1 after transplantation). Two of the 3 patients with a stroke diagnosis before transplantation recovered and eventually underwent heart transplantation., Conclusions: With axillary IABP support, most patients were able to ambulate and undergo physical rehabilitation while waiting for heart transplantation. This study demonstrates that axillary IABP results in a high success rate of bridge to transplantation and a low number of complications. Thus, an ambulatory axillary IABP provided efficient and safe support for selected patients as a bridge to heart transplantation., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The femoral artery is generally used as primary access for transcatheter aortic valve implantation. However, peripheral artery disease often precludes femoral access. The purpose of this study was to describe clinical outcome of transcatheter aortic valve implantation using the left axillary artery (LAA) as primary access site., Methods: From December 2008 until June 2016, data on all consecutive patients treated with a Medtronic device through the LAA at our hospital were registered, and outcome was prospectively collected according to the updated Valve Academic Research Consortium-2 criteria. Mortality check was performed nationally., Results: In total, 362 patients were included (median age 80 years [range, 76 to 84]; logistic European System for Cardiac Operative Risk Evaluation 17% ± 12%). Successful axillary access was achieved in 99%. Medtronic CoreValve (86%) and Evolut R (14% [Medtronic, Minneapolis, MN]) were implanted. Major vascular complications occurred in 5% of patients, 1% was LAA related. Life-threatening bleeding and major bleeding were observed in 2% and 10%, respectively. Additional complications were new left bundle branch blood (30%), new permanent pacemaker (11%), and stroke (1%). There were 6 procedural deaths (2%) and 19 deaths (5%) within 30 days. One-year mortality rate was 19%., Conclusions: This is the first study reporting outcome after transcatheter aortic valve implantation using the LAA as default access. We conclude that it is highly feasible and safe with low rates of major vascular complications, bleeding, and stroke., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In morbidly obese patients who cannot undergo transfemoral, transaortic, or transapical transcatheter aortic valve replacement (TAVR) due to body habitus, suprasternal (SS) and left subclavian/axillary artery (LSCLA) approaches may provide safe TAVR access. Nine morbidly obese patients with a body mass index of 35 or more underwent SS-TAVR (7 patients) or LSCLA-TAVR (2 patients) at two institutions from 2015 to 2017. Mean age was 69.4 ± 7.3 years, and mean body mass index was 50.3 ± 10.6. There were no deaths, valve reinterventions, or reoperations. Three patients required new pacemakers. In morbidly obese patients who are not candidates for the other approaches, SS-TAVR and LSCLA-TAVR allow easier vascular access and prevent the need for thoracotomy or sternotomy., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Iliofemoral arterial disease can preclude transfemoral (TF) transcatheter aortic valve replacement (TF-TAVR). Transthoracic access by direct aortic or a transapical approach imparts a greater risk of complications and death than TF access. We hypothesized that subclavian/axillary arterial (SCA) access offers equivalent risks and outcomes as TF access., Methods: The outcomes of 202 patients from the CoreValve (Medtronic, Minneapolis, MN) United States Pivotal Trial Program treated with SCA access were propensity matched with patients treated with TF access and analyzed., Results: Matching was successful, with no significant baseline differences in the SCA group and the TF group, except the SCA group had more past or present smokers (79.2% vs 61.4%, p < 0.001) and fewer patients with anemia requiring transfusion (18.5% vs 27.5%, p = 0.04). SCA patients experienced a significantly longer time from enrollment to procedure (8.6 ± 19.1 vs 5.3 ± 6.3 days; p = 0.02), likely the result of case planning. Significant differences in procedural outcomes include less post-TAVR balloon dilation (17.9% vs 26.7%, p = 0.03) and more general anesthesia (99.0% vs 89.6%, p < 0.001) for the SCA accesses. There were no differences in procedure time (57.8 ± 45.3 vs 57.5 ± 32.1 min, p = 0.94) or Valve Academic Research Consortium I-defined procedure success between groups (p = 0.89). Event rates at 30 days or 1 year were similar, with a trend toward fewer pacemakers with SCA accesses., Conclusions: Major morbidity and mortality rates SCA-TAVR are equivalent to TF-TAVR. The SCA should be the preferred secondary access site for TAVR because it offers procedural and clinical outcomes comparable to TF-TAVR and applies to most patients who are not TF candidates., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Cannulation and perfusion in extensive aortic dissection involving the neck and femoral vessels is challenging in view of false lumen cannulation and attendant malperfusion syndromes. Although a number of methods have been described, our technique of cannulation and perfusion through right atrial-to-left atrial bypass and innominate artery transection ensures adequate brain perfusion and visceral organ true lumen perfusion during the entire duration of cardiopulmonary bypass. This procedure can be applied to all varieties of extensive type A aortic dissections involving the neck and femoral vessels. A step-by-step of how to do it has been described., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Transcatheter aortic valve implantation has been designed to treat older patients affected by severe aortic stenosis who are considered high-risk surgical candidates because of multiple comorbidities. The least invasive approach for transcatheter aortic valves implantation should be considered the transfemoral retrograde route, because it is minimally invasive and is feasible with local anesthesia and mild sedation. Despite significant technical improvements in recent years, the transfemoral approach is contraindicated in cases of severe peripheral artery disease. We describe the first case of a Portico transcatheter aortic valve implantation system (St. Jude Medical, Minneapolis, MN) made through the distal axillary artery in a 90-year-old patient affected by severe aortic stenosis., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The choice of an optimal cannulation site for aortic repair in patients with Stanford A acute aortic dissection remains controversial. The aim of this study was to compare the early results and long-term outcomes of axillar and direct aortic cannulation., Methods: A total of 235 consecutive patients who underwent surgical aortic repair with the use of axillar or direct aortic cannulation from January 2006 to April 2015 were analyzed. The primary end points were long-term overall cumulative survival and freedom from major cerebrovascular events with up to 10 years of follow-up. The secondary end points were early postoperative clinical characteristics and rates of adverse events. To control for confounders, a 1:3 propensity score matching was performed., Results: After matching, there were no statistically significant differences between the two groups regarding baseline characteristics. Both groups were associated with comparable outcomes; among other things, the length of stay in the intensive care unit (ICU) (p = 0.220), mechanical ventilation (p = 0.177), total hospital stay (p = 0.243), and hospital rates of adverse events. There were no statistically significant differences (p = 0.625) in terms of freedom from major cerebrovascular events. However, both early (p = 0.009) and late (p = 0.016) overall survival were significantly poorer for patients undergoing aortic cannulation., Conclusions: The outcomes were comparable regarding early hospital outcomes and rates of adverse events. Whereas postoperative freedom from major cerebrovascular events was similar, survival over long-term follow-up was significantly poorer when direct aortic cannulation was used. More investigations are needed to enable an understanding of the underlying factors for potentially higher late mortality when direct aortic cannulation is used during a surgical procedure for acute Stanford A dissection., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Debate regarding the optimal cannulation site for aortic surgery continues. We report our recent experience with a simple and rapid open Seldinger-guided technique for femoral cannulation. Aside from speed and simplicity (no need for arterial incision or suture closure), this technique has the added benefit that the distal limb continues to be perfused, as no arterial snare is required., Methods: We recently began routinely utilizing an open Seldinger-guided technique for femoral artery cannulation. The artery is exposed surgically but cannulated by guidewire inside a pursestring without arterial incision. The pursestring is simply tied when decannulation is performed. We report our experience with the routine application of this technique from August 2011 to April 2015., Results: We reviewed the outcome of 337 consecutive peripheral arterial cannulations performed for thoracic aortic surgery (303 femoral, 34 axillary) using the open Seldinger technique. Within the femoral cannulation group, the hospital survival rate was 97% (295 of 303). The survival rate for elective operations was 98% (277 of 283), and 90% (18 of 20) for emergent/urgent. Seldinger-guided femoral cannulation was performed for replacement of the ascending/aortic arch in 88% (266 of 303), the descending thoracic aorta in 7% (22 of 303), and the thoracoabdominal aorta in 5% (15 of 303). There were no instances of intraoperative malperfusion phenomena, arterial dissection, or vascular injury or rupture. No patients had postoperative acute limb ischemia. Local wound complications were observed in 1% of patients (3 of 303). The stroke rate was 1.6% (5 of 303). The same open Seldinger technique was also used without complication in the axillary cannulation group., Conclusions: An open Seldinger-guided femoral (or axillary) cannulation technique is quick and easy to perform, with minimal vascular or other complications and extremely low risk of stroke. This technique is recommended for its speed, simplicity, and effectiveness, and for its preservation of distal arterial flow (which is occluded with the traditional arterial incision/arterial snare technique)., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Arterial cannulation into the right axillary artery is a commonly adopted perfusion strategy in the treatment of acute aortic dissection. Here we describe our experience of accidentally cannulating the axillary artery in a case of acute aortic dissection with an aberrant right subclavian artery, which was missed preoperatively because its proximal segment was malperfused by the dissection and thereby not enhanced. The rapid hemodynamics collapse at the start of the bypass was reversed by prompt switching to femoral perfusion. Postoperative follow-up computed tomographic angiography revealed a well-perfused right aberrant subclavian artery. Surgeons should be aware of an aortic arch anomaly whenever performing an axillary artery cannulation., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We treated a patient with acute aortic dissection, which affected the innominate and carotid arteries. Although the true lumen was adequately wide and cerebral malperfusion deemed unlikely, extracorporeal circulation through the femoral artery caused right cerebral malperfusion, and addition of right axillary artery perfusion was ineffective. Several minutes after innominate artery snaring, cerebral blood flow was suddenly restored and the clinical outcome was favorable. Axillary artery perfusion is occasionally unreliable and inevitably demands careful cerebral flow monitoring. A dead-end false lumen in the innominate and carotid arteries requires special caution. A dual-artery perfusion strategy permits innominate artery occlusion as an emergency measure against unexpected malperfusion., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Transcatheter aortic valve implantation (TAVI) is an accepted alternative treatment for severe symptomatic aortic stenosis in high-risk and inoperable patients. Femoral or transapical accesses are commonly used. We report our initial clinical experience with TAVI using the left-axillary artery approach., Methods: A single-center, retrospective study of patients undergoing transaxillary TAVI between January 2010 and December 2012 was performed. Procedural success was defined as successful device implantation with reduction in the mean aortic gradient and without need for conversion to open-heart surgery. Short-term echocardiographic follow-up was obtained in all patients., Results: A total of 18 consecutive patients with severe aortic stenosis who were not candidates for surgical replacement underwent transaxillary TAVI. Mean age was 81.1±7.3 years and 14 patients (78%) were male. Median logistic European System for Cardiac Operative Risk Evaluation was 8.5% (range, 1.5% to 54.1%). Procedural success was obtained in 17 out of 18 patients (94%). There was no in-hospital or 30-day mortality. One major bleeding complication in the form of an upper gastrointestinal bleeding was observed. No stroke or major vascular complication was reported. Postoperative implantation of a permanent pacemaker was performed in 7 patients (39%). At a mean follow-up of 326±213 days, mean aortic gradient was 10.8±4.8 mm Hg. Mean aortic valve area was 1.7±0.4 cm2 and aortic insufficiency grade was mild or less in all but 1 patient, who showed moderate regurgitation., Conclusions: The transaxillary approach for TAVI is associated with high procedural success and low rates of stroke, vascular, or bleeding complications. This approach is an appealing alternative to the commonly used transfemoral and transapical TAVI., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Endovascular repair of emergent syndromes involving the ascending aorta is uncommon. We describe an acute disruption of the ascending aorta during stenting of the pulmonary artery, resulting in an acute aortopulmonary artery defect and severe pulmonary edema. The disruption was treated successfully using an endovascular approach, with rapid resolution of the patient's pulmonary edema., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The impact of antegrade versus retrograde perfusion during cardiopulmonary bypass on short- and long-term outcome after repair for acute type A aortic dissection is controversial., Methods: We reviewed 401 consecutive patients (age, 59.2 ± 14 years) with acute type A aortic dissection who underwent aggressive resection of the intimal tear and aortic replacement (March 1995 through July 2011). Arterial perfusion was antegrade in 78% (n = 311), either by means of the right axillary artery (n = 297) or through direct aortic cannulation (n = 15). Retrograde perfusion through the femoral artery was used in 22% (n = 90)., Results: Of the 401 patients with acute type A aortic dissection, 16% (n = 64) presented in critical condition and 10% (n = 39) entered the operating room under cardiopulmonary resuscitation. In 14% (n = 54) the dissection did not extend beyond the ascending aorta (DeBakey II); 82% of dissections did involve at least the aortic arch (n = 326, DeBakey I+III). Mean age was not significantly different between patients undergoing antegrade (59.4 ± 14 years) versus retrograde (59.2 ± 13 years; p = 0.489) perfusion. Operative mortality was 20% and did not differ significantly between the groups (p = 0.766); postoperative stroke occurred also with a similar prevalence (antegrade, 15% versus retrograde, 18%; p = 0.623). Patients undergoing antegrade perfusion had a better long-term survival. Survival at 10 years after discharge was 71% versus 51% (p = 0.025) in favor of antegrade perfusion. Retrograde perfusion was identified to be an independent risk factor for late mortality in multivariate analysis (hazard ratio = 2; p = 0.009)., Conclusions: Survival during the initial perioperative period was equivalent comparing antegrade and retrograde perfusion. Antegrade perfusion to the true lumen, however, appears to be associated with superior long-term survival after hospital discharge., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Currently, right axillary artery cannulation and unilateral antegrade cerebral perfusion through the same cannula are preferred choices for acute type A aortic dissection repair. However, the existence of an aberrant right subclavian artery can jeopardize cerebral perfusion through the right axillary artery cannula. In this study, we intended to explain the repair of acute type A aortic dissection using right axillary artery cannulation in a patient with aberrant right subclavian artery., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A primary predictor for success with catheter-based treatment of structural heart disease is having safe remote access to the heart. The devices for transcatheter aortic valve replacement require large-bore access, but many patients with severe aortic stenosis also have iliofemoral disease or relative contraindications to transapical access. In such situations, the leading alternative vascular access site has been the axillary or subclavian artery. This approach has been used with increasing frequency, and as these new devices become more readily available, it is anticipated that the experience will grow. Literature on the use of this access site for transcatheter aortic valve replacement is reviewed to highlight the current understanding about safety of this approach., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Perfusion through the right axillary artery is an alternative to aortic or femoral artery cannulation during surgery for ascending aortic dissections. The results of this strategy, particularly beyond the immediate postoperative period, are not well described., Methods: Eighty-three patients (median age, 58 years) with acute or subacute ascending aortic dissection underwent surgical repair with right axillary artery perfusion through an interposition Dacron graft. Sixty-five patients (78%) had DeBakey type I dissections. Procedures performed concomitantly with ascending aortic replacement included root replacement (n = 16; 19%), aortic valve repair or replacement (n = 51; 61%), and coronary artery bypass grafting (n = 13; 16%). Hypothermic circulatory arrest with antegrade cerebral perfusion was used in the majority of patients (n = 60; 72%). We retrospectively studied short-term and midterm outcomes, including survival and complications relating to the axillary cannulation., Results: No patient incurred intraoperative axillary artery injuries or had arm ischemia. Fourteen patients (17%) died in the hospital or within 30 days of surgery, and 9 patients (11%) had strokes. Actuarial survival was 73% +/- 5% at 1 year and 64% +/- 6% at 3 years. Forty-six of the 57 surviving patients could be contacted by telephone; they reported few late complications related to the axillary artery cannulation site. These complications included 1 case each of right-arm weakness and right-arm numbness., Conclusions: Surgical repair of acute aortic dissection with right axillary artery perfusion can be performed safely, with a relatively low risk of stroke and a high probability of midterm survival., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We describe preemptive placement of a TandemHeart percutaneous left ventricular assist device (CardiacAssist Inc, Pittsburgh, PA) through the axillary artery and vein for temporary postoperative support in a patient with severe left ventricular dysfunction undergoing high-risk cardiac reoperation. We believe this approach is preferable to high-dose catecholamines because of preserved early tissue perfusion without excessive vasoconstriction. Axillo-axillary placement is advantageous because patients can sit up and partially mobilize, and there is no need to reopen the chest for explantation., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Upper extremity vascular compromise from thoracic outlet syndrome is rare and is usually the result of a "cervical rib," anterior scalene muscle abnormality, or clavicular trauma. We report a case of acute axillary artery thrombosis secondary to a congenital acromioclavicular remnant in a 40-year-old woman.

Background: The impact of axillary artery cannulation (AXC) on survival and neurologic outcome after operation for ascending aortic disease was retrospectively evaluated., Methods: We reviewed 869 patients with ascending aorta/root repairs (1995 to 2005), principally for atherosclerotic and degenerative aneurysms and chronic and acute type A dissections. Arterial cannulation was through the ascending aorta (AAC) in 157 patients, the femoral artery (FAC) in 261, and the right axillary artery (AXC) in 451. Patients cannulated at different sites were compared for preoperative comorbidities and outcomes (mortality and stroke) for each cause., Results: Of the 122 patients with atherosclerotic aneurysms, 66 with right AXC had significantly better outcomes (p = 0.02): 64 of 66 survived vs 24 of 26 with FAC and 27 with 30 of AAC; no strokes occurred (vs 2 of 26 with FAC and 4 of 30 with AAC). No significant advantage for AXC was found with ascending aortic operation in 495 degenerative aneurysms, 106 chronic, or 65 acute type A dissections, 41 patients with endocarditis, or in 18 with aneurysms of other causes; AXC was associated with a significantly better outcome (p = 0.05) in the 869 patients taken together., Conclusions: AXC resulted in superior survival and neurologic outcome in patients with atherosclerotic aneurysms and a marginally better outcome than with cannulation at other sites during proximal aortic procedures for all causes. This study supports AXC in patients with atherosclerotic disease who require complex cardiothoracic operations and in patients requiring proximal aortic intervention regardless of cause.

As a ventricular unloading catheter, the Impella Recover LP 5.0 (Abiomed, Danvers, MA) is appropriate for temporary circulatory assistance in severe left ventricular dysfunction. We describe a new implantation approach to the right axillary artery with the aims of avoiding vascular problems due to atherosclerosis of the peripheral arteries and improving patient mobility and rehabilitation during mechanical support.

Aortic arch surgery necessitates interrupted brain perfusion and carries a risk of brain injury. Various brain protective techniques have been advocated to reduce risk including hypothermic arrest and retrograde or selective antegrade perfusion. Knowledge of the pathophysiologic consequences of deep hypothermia, may aid the surgeon in deciding when to initiate circulatory arrest and for how long. Retrograde cerebral perfusion use was advocated to prolong safe arrest durations but may not improve outcomes. Selective antegrade cerebral perfusion appears to have become the preferred method of brain protection. However, the delivery conditions and optimal perfusate constitution require further study.

Background: Right axillary artery cannulation and selective antegrade cerebral perfusion (SCP) have become well-described strategies in the surgical treatment of proximal aortic disease. Many series report increases in adverse outcomes with SCP used in emergent settings. We compare outcomes in elective and emergent patients., Methods: Over 21 months, SCP through right axillary cannulation with a side graft was performed in 61 patients. Thirty-three percent (20 of 61) underwent emergent operation for Stanford type A dissection or intramural hematoma, including 3 of 20 (4.7%) with pericardial tamponade; the remainder of SCP (41 of 61) was elective. The mean follow-up was 9.1 +/- 0.40 months., Results: Selective antegrade cerebral perfusion was used in 20 of 22 emergent cases (91%), with 2 unsuccessful cannulation attempts, and no peripheral arterial dissections encountered. The SCP flows averaged 16.3 +/- 0.71 cc x kg(-1) x min(-1) for a mean perfusion period of 26.1 +/- 1.9 minutes. The average cardiopulmonary bypass time for all patients was 173 +/- 11 minutes. Average hospital stay was 8.1 +/- 0.80 days. One case (1.3%) of permanent and 3 cases (4.8%) of temporary neurologic dysfunction occurred in SCP patients. The hospital mortality rate for emergent SCP cases (2 of 20, 10%) was not statistically different from the mortality rate for elective SCP cases (3 of 41, 7.3%, p = not significant), with no difference in complication rates. All 3 SCP patients with preoperative tamponade survived without complication. Cerebral oximetry data showed a trend toward decreased left-sided (contralateral) scalp perfusion. There was no association of emergent status with neurologic dysfunction, death, or any other adverse outcome., Conclusions: Axillary cannulation and SCP in the surgical treatment of proximal aortic pathology is safe in both elective and emergent settings.

Extracorporeal membrane oxygenation can be instituted through various cannulation sites. This paper describes a technique for axillary artery cannulation for inflow perfusion in extracorporeal membrane oxygenation and discusses both potential advantages and limitations. Exposure of the artery was achieved through the deltoid-pectoral approach. Both direct cannulation and interposition graft cannulation are possible, but the latter is preferred. Advantages of axillary artery cannulation are related mainly to the establishment of "central" support with antegrade flow and excellent upper body oxygenation. It also affords chest closure after postcardiotomy shock, and easy control of any mediastinal bleeding. These cannulation sites may be options for the institution of venoarterial extracorporeal membrane oxygenation, especially in postcardiotomy and respiratory failure patients and in patients with significant peripheral vascular disease.

Background: We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest., Methods: Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression., Results: Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs)., Conclusions: Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

Background: Recently, surgeons have embraced axillary artery cannulation for type A aortic dissection repair out of concern for malperfusion phenomena with traditional femoral artery cannulation. My colleagues and I sought to determine whether these concerns are justified., Methods: Records of 86 consecutive patients (51 men and 35 women; age, 30 to 86 years; mean, 62 years) undergoing surgical repair for acute type A dissection were reviewed. Cannulation site, specific operative repair, and complications related to cannulation were noted., Results: Seventy-nine cannulations were performed in the femoral artery (47 left, 23 right, and 9 unspecified), 3 in the axillary artery (1 left and 2 right), and 4 in the ascending aorta or arch. Deep hypothermic arrest was used in 64 operations. Seven involved re-sternotomy. Seventy patients had supracoronary grafts (2 with valve replacement and 10 with valve resuspension), and 16 underwent aortic root replacement. Fourteen patients were in shock from cardiac tamponade. Eighty patients survived the operation, and 71 were hospital survivors. Malperfusion on initiation of cardiopulmonary bypass was noted in 3 patients. In 1, the original cannulation site was the ascending aorta, and the cannula was moved to the femoral artery for correction. In 2, the original cannulation site was the femoral artery, and the cannula was moved to the ascending aorta. Malperfusion on clamping of the aorta or on resumption of aortic flow was noted in no patient. Postoperative ischemia of any vascular bed was noted locally only in 3 (cannulated) lower extremities., Conclusions: Straight femoral cannulation for all phases of type A dissection repair is appropriate and yields excellent clinical results. The anticipated malperfusion events are actually rare (2 of 79 with femoral artery cannulation, or 2.5%).

Background: The axillary artery is our preferred arterial cannulation site when the ascending aorta cannot be cannulated. Previously, we cannulated the artery directly; now we use a side graft. The purposes of this study were to (1) investigate cannulation-related morbidity and (2) determine whether use of a side graft reduces it., Methods: From January 1993 to January 2001, 392 patients underwent 399 axillary artery cannulations. Indications included calcified ascending aorta (129, 32%), ascending aortic aneurysm (115, 29%), type I aortic dissection (85, 21%), cardiac reoperation (70, 18%), and calcified femoral artery (26, 6%). The axillary artery was cannulated directly in 212 (53%) and with a side graft in 187 (47%). Comparisons of cannulation-related morbidity between the direct cannulation and side graft groups were made overall and after both adjusting and matching for propensity score., Results: Cannulation-related morbidity was infrequent, with brachial plexus injury in 7 (1.8%), axillary artery damage in 7 (1.8%), aortic dissection in 3 (0.8%), and arm ischemia in 3 (0.8%). Only 4 of 187 (2.1%) occurred in the side graft group, versus 16 of 212 (7.0%) with direct cannulation (p = 0.03). After propensity adjustment, the odds ratio for reduction of risk of cannulation-related morbidity with use of a side graft was 0.15 (p = 0.002)., Conclusions: Use of the axillary artery as inflow for cardiopulmonary bypass is associated with low morbidity. However, cannulation with a side graft was associated with less cannulation-related morbidity than direct cannulation. Routine use of a side graft is recommended whenever axillary artery cannulation is indicated.

Background: Systemic artery to pulmonary vessel fistulas (SAPVF) occur through pleural adhesions from miscellaneous origin. We report 3 cases of acquired SAPVF that developed late after thoracotomy., Methods: There was one pleurectomy for pneumothorax, one sleeve main bronchial resection, and one lower-middle bilobectomy. These SAPVF were discovered 4, 18, and 21 years after surgery., Results: One patient underwent two unsuccessful embolizations. One patient underwent an unsuccessful attempt at surgical treatment after a previous embolization. Both have persistent SAPVF with minimal clinical discomfort 5 and 13 years later. One patient remains without treatment., Conclusions: In the literature 13 cases of SAPVF have been reported after lung resection, pleural drainage, axillary abcess drainage, closed chest trauma, parietal pleurectomy, and talc poudrage. Potential treatments of SAPVF include embolization, resection of pleural adhesion, and artery ligation. The effectiveness of these techniques is uncertain and the follow-up is too short to draw any clear conclusions. Embolization seems to be a useful tool in case of a single afferent artery. Surgical treatment seems to achieve more durable results than embolization but carries a higher risk of bleeding in the case of large SAPVF. Because SAPVF are well tolerated and complications are uncommon, clinical follow-up may be warranted in most cases.

Background: The ascending aorta is the customary site for arterial cannulation for cardiopulmonary bypass. Favorable experience at our institution and elsewhere using axillary artery cannulation in treating type A aortic dissections has caused us to broaden our indications for using this site for arterial cannulation for cardiopulmonary bypass., Methods: Medical records, operative notes, and perfusion records were reviewed in all patients in whom the axillary artery was cannulated directly or by a graft for cardiopulmonary bypass from January 1, 2000 through August 30, 2002., Results: Seventy-five patients underwent axillary artery cannulation during the 32-month interval. Eleven patients had ascending aortic dissections, 20 had extensively diseased ascending aortas, and 44 were individuals undergoing repeat cardiac procedures. The right axillary artery was used in 72 patients and the left in 3. In 16 patients the artery was cannulated directly, and in 59 the arterial cannula was inserted into a prosthetic graft that had been anastomosed to the axillary artery. Axillary artery cannulation was satisfactory in 95% (71 of 75) of the cases in which it was used., Conclusions: Cannulation of the axillary artery for cardiopulmonary bypass is a dependable approach for procedures including reoperations, aortic dissections, and extensively diseased ascending aortas.

Perfusion from the femoral artery is commonly used in the open proximal method of performing distal aortic arch aneurysm repair or Stanford type B aortic dissection repair under circulatory arrest through left thoracotomy. However, it is associated with a significant risk of retrograde emboli or malperfusion, and with other problems including a restricted time of circulatory arrest to the brain and difficulties in de-airing from the arch branches and proximal ascending aorta. To overcome these problems, we developed a method of performing right axillary perfusion through left thoracotomy.

Background: Peripheral arterial and venous cannulation for cardiopulmonary bypass is used increasingly for patients undergoing minimally invasive cardiac operations, complex reoperations, or repair of aortic dissection or aneurysm, and for patients with extensive arteriosclerotic aortic disease in whom aortic cannulation is a prohibitive embolic risk. The common femoral artery and vein are most commonly used for peripheral cannulation, but these sites may be predisposed to complications, primarily because the femoral vessels are commonly involved with arteriosclerotic disease. We have recently begun to use the axillary artery and axillary vein as alternative cannulation sites, achieving full cardiopulmonary bypass, providing antegrade aortic flow, and avoiding many of the complications associated with other sites., Methods: Seven patients with peripheral vascular or aortic disease, or both, prohibiting safe aortic or femoral cannulation underwent cardiopulmonary bypass through axillary artery and axillary vein cannulation, approached through a small single subclavicular incision., Results: All patients were successfully cannulated and axilloaxillary cardiopulmonary bypass was possible without the need for additional cannulas. All axillary vessels were closed primarily without complication., Conclusion: For an expanding population of patients with peripheral vascular and aortic disease, axilloaxillary bypass is a safe and practical alternative to aortic or femoral cannulation.