ARTERIAL

CANNULATION
Arterial Cannulation

The basic purpose of the arterial cannula is to allow oxygenated blood to be delivered to the arterial circulation.

Arterial cannulation is generally established before venous cannulation to allow volume resuscitation of the patient,
should it be necessary.

The ascending aorta is the preferred site for aortic cannulation because
• it is easily accessible,
• does not require an additional incision,
• accommodates a larger cannula to provide greater flow at a reduced pressure,
and carries a lower risk of aortic dissection compared with other arterial cannulation sites
• no risk of limb ischemia
Types of cannulas:
Some are right-angled tips,
some are tapered,
and some have flanges to aid in fixation and
to prevent the introduction of too great a length into the aorta.

The arterial cannula is usually the narrowest part of the ECC.

High flow through narrow cannulas may lead to high pressure gradients, high velocity of flow (jets), turbulence, and
cavitation

A useful descriptive characteristic of an arterial cannula is its “performance index” (pressure gradient vs. OD at any
given flow) .

The narrowest portion of the catheter that enters the aorta should be as short as compatible with safety, and thereafter
the cannula size should enlarge to minimize the gradient.
Long catheters with a uniform narrow diameter are undesirable.

The use of thin metal or hard plastic (e.g., polycarbonate) for the tip provides the best ID-to-OD ratio.
Pressure gradients exceeding 100 mmHg are associated with excessive hemolysis and protein denaturation .
Therefore, it is preferable to select a cannula that will provide adequate flow with no more than 100-mmHg pressure
gradient
Aortic Cannulation

Technique
, In the early days of CPB, arterial inflow was through the subclavian or femoral artery,

currently, as first proposed

by Nunez and Bailey in 1959 , it is usually through the cannula inserted into the ascending aorta

The site for cannulation is selected on the basis of

• the type of cannula to be used,
• the operation planned (i.e., how much of the ascending aorta is available),
• the quality of the aorta,
• and the surgeon’s preference.
• The aorta should be routinely palpated for localized thickening and calcific plaques.

Mills and Everson recommend using a 10- to 20-second period of venous inflow occlusion to reduce systemic arterial
pressure to 40 to 50 mmHg to improve the reliability of palpation of the ascending aorta.

• Transesophageal echocardiography and epiaortic ultrasonographic scan of the ascending aorta are more sensitive
for confirmation and localization of atheromatous changes.

Beique et al. (85) suggested using epiaortic scanning in all patients who have a
• history of transient ischemic attacks, strokes,
• severe peripheral vascular disease,
• and palpable calcification in the ascending aorta,
• calcified aortic knob on chest X-ray,
• those older than 60 years,
• and those with TEE findings of moderate aortic atherosclerosis.
intraoperative TEE or epiaortic ultrasound scanning of the aorta should be considered (Class IIa, level of evidence B)”

that “epiaortic ultrasound-guided changes in surgical approach (provide) neuroprotection during CPB (IIb)” ,

“routine epiaortic ultrasound scanning is reasonable to reduce the incidence of atheroembolic complications (Class
IIa, level of evidence B)” .

If atherosclerosis is detected, then the sites for insertion of cannulas, grafts, and application of vascular clamps
are modified.

If extensive atherosclerosis precludes arterial cannulation in the ascending aorta, then the femoral route should be
considered .

However, in this case, the transverse and descending aorta should be evaluated by TEE to rule out extensive atheroma
that might be embolized into the brain or elsewhere with retrograde flow from a femoral cannula.

If such is the case, then axillary-subclavian or innominate artery cannulation should be considered.
• The site for cannulation should be disease-free if possible.

Usually, the anterior aspect of the aorta just proximal to the base of the innominate artery or the segment along the
inner curvature of the aorta adjacent to the pulmonary artery is relatively free of calcification.

Epiaortic scanning should be performed before the placement of the purse-string sutures.

The pericardial cavity is filled with warm saline and the aortic arch and ascending aorta are scanned.
In preparation for cannulation, systemic heparin must be given to achieve an activating clotting time of more than
500seconds
The systolic blood pressure requires strict control whenever the aorta is manipulated, especially for cannulation and
decannulation
• Small bites of the adventitia and media as high up on the aorta as feasible are taken with 3-0 Prolene
sutures on noncutting needles to form a single or double purse-string.

• A stab wound is made within the purse-string sutures.

The tip of the aortic cannula is then introduced atraumatically into the opening .

Only 1–2 cm of the cannula tip is advanced and directed towards the arch to avoid inadvertent cannulation of the
head and neck vessels or dissection of the posterior wall of the aorta

The cannula is placed in the center of two circumferential purse strings with tourniquets.

The inner purse string is sized to be larger than the tip of the arterial cannula.

• The tubing is then tied to the aortic cannula and, if desired, further secured to the edges of the wound
.

• The aortic cannula is allowed to fill retrogradely with blood.then clamped, It is then connected to the
arterial line, making sure that all air has been removed from the circuit.
prior to connecting to the arterial infl ow circuitry of the CPB machine.

During connection to the circuit it is essential to ensure that no air is present at the connection site.

When the connection is complete the perfusionist will inform the surgeon of the “swing” on the arterial pressure line

and the pressure within the system to confi rm correct intraluminal placement of the cannula.

After the arterial cannula is inserted, a test infusion with the systemic pump through the arterial line before initiating
CPB is recommended (regardless of location of the arterial cannula,

. A higher-than-expected pressure in the circuit arterial line warns of possible dissection and may help avoid a more
extensive dissection.

Another method described by DeBois and colleagues The lack of negative flow or a flow of <500 mL/min during
retrograde arterial priming suggests cannula misplacement or occlusion
• The sutures can be buttressed with felt or pericardial pledgets to prevent bleeding from the needle holes.

•
• The ends of the purse-string sutures, which have passed through a long, narrow rubber or plastic tube, are
secured
Optimal arterial blood pressure during cannulation (mean arterial pressure of approximately 70 to 80
mmHg, systolic pressure of approximately 100 to 120 mmHg) is probably important:

if too high, there may be a greater chance of tears and dissection and blood loss and spray;

if too low, the aorta tends to collapse,

, and there is a greater risk of damaging the back wall of the aorta.

An appropriately long full-thickness incision is then made, and the leak is controlled with a finger or by approximating the
adventitia

These purse-string sutures must penetrate the aortic media, but not the aortic lumen.
In patients undergoing reoperation with scarred aortic walls or pediatric patients,

• it may be useful to insert an appropriately sized Hegar dilator through the stab wound before
inserting the aortic cannula

• Thin Aortic Wall

Whenever the aortic wall is thin or friable, the pursestring sutures are reinforced with Teflon or pericardial
pledgets on each side of the cannula to prevent any injury to the aortic wall or bleeding from the needle sites

Small-Diameter Aorta
In patients with a relatively small-diameter aorta, the regular cannula may be space occupying, interfering with
satisfactory perfusion.

Plastic right-angled cannulas have good flow characteristics and will not hit the back wall of the aorta.

.
 The jetting effect produced by small cannulas may damage the interior aortic wall, dislodge atheroemboli
(“sandblasting”) and cause arterial dissections, and disturb the flow into nearby vessels.

Several new designs of aortic cannulas have been introduced to disperse the flow out of the cannulas tips to
reduce the sandblasting effect
If atheroma is extensive in the ascending or transverse aorta, its suggested using a long arterial cannula that is inserted in
the ascending aorta and threaded around into the proximal descending aorta to reduce the“sand-blasting” effect .

Also dvocated doing an endarterectomy under deep hypothermic circulatory arrest (DHCA)

Porcelain, Lead Pipe, or Eggshell Aorta

Porcelain, lead pipe, or eggshell aorta is the term used when the entire ascending aorta is calcified.
Cannulation or clamping of this kind of aorta has catastrophic complications, namely, strokes and uncontrollable
hemorrhage.
In such cases, the femoral or axillary artery and right atrium are cannulated and the aorta is replaced or dealt with under
deep hypothermic circulatory arrest

If there is no intraluminal debris, Liddicoat et al. used an intraluminal balloon designed for port-access surgery, which is
inserted through a purse-string suture in an atherosclerosis-free portion of the aortic arch to occlude the aorta.

Others used a urinary (Foley) catheter in a similar manner .

Complications of aortic root cannulation
Inability to introduce the cannula
• adventitia occluding the incision site

• i nadequate incision size

• atheromatous plaque within aortic wall

Intramural placement

Embolization of atheromatous plaque

Air embolization on connection to the circuit

Persistent bleeding around cannula

Malposition of tip towards aortic valve or into arch vessels

Dissection of aorta
Kink in circuit

Inadequate size leading to high pressure and low fl ow generation

Aneurysm formation at site of cannulation at later stage
atherosclerosis is often more severe in the aortic arch, against which the jets from these short cannulas are directed,
which may become the source of cerebral emboli, especially when the ascending aorta is relatively free of
atherosclerosis.

high-grade plaque with greater frequency in the arch (18%) than in the ascending aorta (5.3%), and Weinstein has
attributed the fact that more strokes occur in the left than the right
cerebral hemisphere to jets striking atheroma in the arch.

To minimize this risk, directing the jet toward the ascending aorta (when it is free of atherosclerosis)
and/or the use of dispersion type arterial cannulas.

As mentioned earlier, others have advocated threading a long cannula into the proximal descending aorta to reduce the
velocity and turbulence in the aortic arch to reduce the “sand-blast” effect and emboli
Inadvertent cannulation of the arch vessels or directing the jet into an arch vessel may cause irreversible cerebral
injury and reduced systemic perfusion.

high systemic line pressure in the CPB circuit; high pressure in the radial artery if supplied by the inadvertently
cannulated vessel (or low pressure if not supplied by the cannulated vessel);

unilateral facial blanching when initiating bypass with a clear priming solution;
asymmetric cooling of the neck during perfusion cooling; and unilateral hyperemia, edema, petechiae,
conjunctival tearing, or dilated pupils.

Before CPB, palpation of the carotid arteries may reveal asymmetric pulsation (reduced on the cannulated side) and
the
opposite may be observed during pulsatile bypass (increased pulsation on the cannulated side).

Before CPB, the radial artery catheter may reveal sudden damping if the cannula is inserted in the arch vessel
supplying the monitored radial artery.
Coanda effect (in which a jet stream adheres to the boundary wall and hence produces a
lower pressure along the opposite wall) may be associated with carotid hypoperfusion

.
This has been shown experimentally and may account for some cerebral dysfunction after CPB using aortic cannulation. detected
major electroencephalographic EEG abnormalities due to malposition of a cannula
Aortic dissection should be suspected when any of the following are observed:

a sudden decrease in both venous return and arterial pressure, excessive loss of perfusate,

increased circuit arterial-line pressure,

evidence of decreased organ perfusion (oliguria, dilated pupil, electroencephalographic changes,

electrocardiographic evidence of myocardial ischemia),

blue discoloration of the aortic root (because of intramural hematoma),

and bleeding from needle or cannulation sites in the aortic root.

Management usually involves:
prompt cessation of CPB,

recannulation distal to the dissection (usually femoral but occasionally into the distal aortic arch),

induction of deep hypothermia, and a period of circulatory arrest while the aorta is opened and

the extent of the injury analyzed and repaired by direct closure, use of a patch, or replacement of the ascending aorta
with a tubular graft
skin incision is a vertical incision overlying and just slightly medial to the
femoral pulse .

An alternative incision is a slightly oblique incision aligned with the inguinal

ligament to facilitate healing.

◆Lymphatic vessels should be carefully cauterized or ligated to prevent

formation of a lymphocele and persistent drainage.
◆Proximal and distal control of the femoral artery should be
obtained.
A target site for the arteriotomy
should be chosen after considering where the proximal clamp
may be safely placed
and how the repair will be accomplished when the cannula is
removed

The distal vessels may be occluded with separate clamps or

tapes
◆The arteriotomy should be made in a transverse
fashion

and the femoral cannula gently introduced

while an assistant releases the proximal clamp.

The cannula is then secured by tying it

to the proximal snare,

with a second suture securing the tubing to the surface of

the thigh.
Femoral Artery Cannulation
Technique

An incision can be made either over the groin near the inguinal ligament. The femoral sheath is incised

The common femoral artery (or occasionally the external iliac artery) is dissected free for a short distance above
the origin of the profunda femoris branch.

Umbilical tapes are placed around the common femoral artery above the prospective cannulation site as well
as the superficial and profunda arteries distally.

Vascular clamps are applied to the femoral artery both above and below the intended arteriotomy
site.
The profunda artery may be either clamped or snared.

A small transverse arteriotomy is made where the arterial wall appears to be relatively normal. A tapered
cannula of appropriate size is then gently introduced through a transverse arteriotomy into the arterial lumen
and is secured in place
The axillary artery is relatively supercial, free of severe atherosclerotic disease,

permits systemic antegrade perfusion, and allows perfusion to commence prior to chest opening.

Perhaps the greatest asset of axillary artery cannulation is the ability to perform selective antegrade perfusion of the head
during lower body circulatory arrest, which is a valuable technique for aortic surgery.

Cannulation of the axillary artery can be accomplished quickly and ef ciently

. Technique

An approximately 5 to 6 cm incision is made 1 cm inferior

and parallel to the midportion of the right clavicle.

The artery is best approached through the deltopectoral

groove.

The dissection is continued between the fi bers of the

pectoralis major.
.
The cephalic vein is identifi ed in this space where it
penetrates the fascia to join the axillary vein.

The clavipectoral fascia is incised and the pectoralis minor

muscle is retracted laterally.

◆ The artery, which lies superior and deep to the vein, can be
identifi ed by palpation and then

The axillary artery is identied next to the brachial plexus.

After heparin is administered, the artery can
be controlled with clamps, but we prefer to use
a partial occluding clamp at the arteriotomy
site.

An 8-mm tube graft should be anastomosed

to this site and the arterial cannula inserted
into the tube graft.

The cannula is not advanced into the axillary

artery proper, but rather perfuses from within
the graft. 4

◆ At the end of the case, the stump can be

controlled with very large hemoclips applied
transversely, then oversewn with 4-0
polypropylene
Right axillary artery cannulation is especially useful for antegrade cerebral perfusion in aortic surgery
when circulatory arrest may be necessary.

When using right axillary artery perfusion for aortic surgery, a right radial arterial line is
necessary to monitor antegrade cerebral perfusion pressure during the circulatory arrest time.
Comparison of arterial cannulation sites

Ascending aorta/arch Femoral artery Axillary/subclavian

Characteristic

• Accessibility readily separate incision separate incision

• Cannula size unlimited limited limited
Risk of malperfusion of arch vessels yes no possible
Perfusion direction Antegrade Retrograde Antegrade

Risk of limb ischemia no yes yes

Aortic dissection
Incidence 0.01%-0.1% 0.2%-1.0% ˜0.75%
Vent Placement
With institution of extracorporeal circulation, pulsatility decreases and with good drainage may finally cease on
full flow and/or total cardiopulmonary bypass and an empty heart.

However, as bronchial and Thebesian veins drain into the left

atrium and ventricle even with total bypass,

the left ventricle will fill and distend, or blood will spill into the operative field if the heart is entered
and not vented after cross-clamping.

A vent catheter usually has a mandrel or a reinforced but flexible tip, which facilitates its placement.
The venting system,

The heart usually starts to beat soon after the aortic cross-clamp is removed.

When warm blood is administered in a retrograde manner as the aortotomy is being closed in
patients undergoing aortic valve replacement

or as the atriotomy is being closed in patients undergoing mitral valve surgery, the heart may
at times begin to beat spontaneously before the removal of the aortic cross-clamp. Every cardiac
surgery team has its own preference for deairing the heart.
• The venting system, if used, is clamped, and the heart is allowed to fill slowly by reducing the venous
return.

• The cardioplegia administration site on the aorta or a residual opening on the aortotomy site is kept
open with the tip of a right-angled clamp to allow the ejected air bubbles to escape.
• At times, saline or blood can be injected slowly through the left ventricular vent, if in place, to
displace air and blood through the aortic opening.
• The heart is shaken and the left atrial appendage is carefully invaginated into the left atrium to displace air
bubbles.
Venting the Right Heart

The right heart is normally drained or vented by the venous cannula(s)

When bicaval cannulation with caval occlusion is used, venting of the right heart is not provided,

and if the right ventricle is not able to eject, the right heart must be vented by releasing
a caval tourniquet,
placing a separate cannula or cardiotomy suction into the right atrium,

or by surgically opening it to drain into the pericardial sac.

Venting the Left Heart
Purpose of Venting the Left Heart

• to prevent distension of the ventricle,

• reduce myocardial rewarming,
• prevent cardiac ejection of air, and to facilitate surgical exposure.
• Prevention of distension of the left ventricle is desirable to prevent mechanical damage to the muscle from excessive
stretching.
• Myocardial preservation may also be improved by decreasing myocardial oxygen demand (decreased wall tension
due to decreased radius of ventricle),
• facilitating subendocardial perfusion (subendocardial perfusion pressure equals aortic pressure minus left ventricular
pressure),
• preventing pulmonary venous hypertension,
When excessive return of blood to the left heart is encountered, improper function or placement of the venous
cannulas,
an LSVC, PDA, or aortic regurgitation should be considered
Indications for Venting the Left Heart
• Venting of the left heart is indicated whenever the left ventricle is unable to handle the amount of blood that is
returning to it.

• This may occur with cooling,

• ventricular fibrillation,
• aortic cross-clamping,
• and administration of cardioplegia.

• It should be especially anticipated with the onset of CPB and with release of the aortic cross-clamp.
• optimal myocardial recovery after an ischemic insult is best provided by full CPB and venting of the left ventricle .
• Otherwise, myocardial oxygen demand may be considerable, although the left ventricular diastolic pressure is low
and the heart is not ejecting .

• Therefore, left ventricular venting during reperfusion may be warranted in hearts with decreased ejection fraction
or those that have been incompletely revascularized or have sustained a period of severe ischemia.
Ascending aortic (cardioplegia cannula)

Simple; no additional cannula

• Also vents air when aorta is unclamped and when LV starts to eject
• Can be used to monitor aortic root infusion pressure
• Only works when aorta is cross-clamped
• Does not work during administration of antegrade cardioplegia
• Can permit or cause air to be aspirated into the aortic root
Indirect LV (through stab wound in RSPV, through LA and MV)

• Handles all sources of blood causing LV distension

• Best for aortic regurgitation
• Provides optimal decompression of LV
• Avoids problems of direct LV vent
• Somewhat difficult exposure of insertion site
• May be difficult to thread cannula into LV and position correctly
• Risk of bleeding and tears at insertion site in RSPV
• Potential for air entry into the left heart
• Potential problem if mechanical prosthesis in mitral valve
• Potential embolism if there are tumors or clots in LA or LV
Venting through the Right Superior Pulmonary Vein

• Venting through the right superior pulmonary vein is convenient, effective, and our technique of choice.
• After clamping the aorta, the vent catheter is introduced into the left atrium through a stab wound in
the center of a rectangular or oval purse-string suture on the right superior pulmonary vein.
• It is placed through the mitral valve into the left ventricle.
The purse-string suture is then passed through a narrow rubber tube and snugged down

Injury to the Phrenic Nerve

When placing sutures on the right superior pulmonary vein, care should be taken to avoid the phrenic nerve,
which runs on the parietal pericardium along the anterolateral aspect of the right superior pulmonary vein.

Injury to the phrenic nerve is more likely to occur in reoperations

Vent Injury
The catheter should be introduced gently and placed across the
mitral valve into the left ventricle

without excessive force to prevent injury to the mitral valve or

perforation of the left atrium or left ventricle.

This complication is more likely when the heart becomes flaccid

after infusion of cold cardioplegic solution.

An unexplained pooling of blood in the pericardial cavity should herald

the occurrence of such a catastrophe.

The tear should be located and repaired with pledgeted sutures

before continuing with the surgery
Pulmonary Artery Venting
A simple but highly effective method to decompress the heart is to
introduce a vent catheter through a purse-string suture on the
anterior surface of the pulmonary artery .

This technique prevents overdistension of both the right and

left sides of the heart without the risk of systemic air
embolism.

Pulmonary Artery Tear

The wall of the pulmonary artery may at times be paper thin and
delicate, resulting in a tear at the vent site.

This can be prevented by using pledgets on the purse-string

suture.
Venting through the Foramen Ovale
We have found venting the left atrium and left ventricle through the foramen ovale in patients with congenital
heart disease very useful.

Technique
With the right atrium open, a small, right-angled vent is introduced through the foramen ovale and
connected to low suction.

If the foramen ovale is not patent, a stab wound is made in the fossa ovalis.

Before closing the right atrium, the vent is removed, and the opening on the atrial septum is closed with a fine
Prolene suture.
Direct LV (through stab wound in apex)

• Direct and simple

• Avoids going across prosthetic mitral valve
• Handles all sources of blood causing LV distension
• Positioning may be a problem—tip becomes easily obstructed by LV wall or MV apparatus
• Risk of damage to LV and injury to coronary arteries and collaterals (myocardial ischemia)
• May be difficult to control bleeding from stab wound
• Late LV aneurysm
• Potential embolism if there are clots in LV
• Potential for air entry into the left heart
Direct LA (through LA appendage, roof of LA, or
RSPV)

Relatively simple
Avoids going across the MV
Does not handle AR
Potential embolism if there are clots in LA
Potential for air entry into the left heart
Aortic Root Air Venting
Any time the heart is opened, even by simply placing a catheter in a chamber air may collect in the heart which, if not
removed, will embolize with resumption of normal cardiac contractions.

In addition to vigorous attempts at air removal before closing the left heart, use of left heart vents, and repeated aspirations
of left-sided chambers,

the use of venting at the highest point of the aorta is considered the final safety maneuver against systemic air embolism

Brenner et al. analyzed the physiologic principles relevant to the efficiency of aortic root air vents and studied various
systems in vitro model.

They found that a freely bleeding stab wound containing a nonobstructing fenestrated 10F plastic catheter connected to
suction was the most efficient (97%).

A freely bleeding stab wound was almost as efficient (91%), but inserting a catheter into the stab wound that was not
connected to suction decreased its efficiency to 79%