Arterial cannulation

Dr. Sanjana Kamath M.

Arterial cannulation
• The arterial cannula is used to connect the "arterial limb" of the CPB
circuit to the patient
• It delivers oxygenated blood from the heart-lung machine directly into
the patient’s arterial system
• The required size is determined by the size of the vessel that is being
cannulated & blood flow required
• The ascending aorta is the most common site of arterial cannulation
• Arterial cannulas are sized by internal diameter
Sites of arterial cannulation
• Proximal Aorta • Central
• Innominate artery 1. Aorta
2. LV apex
• Distal Aortic arch
• Femoral artery • Peripheral
• External Iliac artery 1. Axillary
• Axillary artery 2. Subclavian
3. Innominate
• Subclavian artery
4. Femoral
Characteristic Ascending Ao/Arch Femoral artery Axillary/Subclavian
Accessibility Readily Requires separate incision Requires separate incision
Cannula size Relatively unlimited Limited Limited
Risk of malperfusion of Yes No Possible
arch vessels
Perfusion direction Antegrade Retrograde Antegrade
Risk of limb ischaemia No Yes Yes
Aortic dissection 0.01-0.1% 0.2-1.0% 0.75%
incidence
Local artery No Yes Yes
complications
Wound infection 0% ~4% <1%
Characteristic Ascending Ao/Arch Femoral artery Axillary/Subclavian
Advantages Convenient Allows peripheral Less risk of
Low risk of dissection cannulation atheroembolism
Allows cannulation before Less malperfusion during
sternotomy in high-risk Sx for Ao dissection
pts. Permits selective
antegrade cerebral
perfusion
Disadvantages Atheroembolism Retrograde dissection Separate ischaemic injury
May not be acceptable Limb ischaemia to brachial plexus and
(eg. Porcelain Aorta) Local wound artery
complications
Indications Most cases When Ao cannulation is When Ao cannulation is
not feasible not feasible or desirable
Peripheral cannulation Aortic dissection Sx
before induction of GA
(Emergency rescue
cannulation)
Contraindications Disease of asc. Ao Occlusive disease in Occlusive disease in
vessel vessel
Extensive atheroma in
desc. Ao or arch
Choice of site
• Atherosclerosis with or without calcification
• Dislodgment of atheromatous debris either by direct mechanical
disruption or from the “sand-blasting” effect of the jet coming out of
the arterial cannula  major cause of perioperative stroke
• Palpation
• Epivascular ultrasonic scanning
• TEE  more convenient but less sensitive
Choice of site
• If atherosclerosis is detected  sites are modified
• If extensive atherosclerosis precludes arterial cannulation in the asc.
Ao  femoral route
However, in this case, transverse and desc. Ao 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  Axillary-subclavian or innominate artery
cannulation should be considered
Choice of site
• If atheroma is extensive in asc./transverse Ao  use a long arterial
cannula that is inserted in asc. Ao and threaded into proximal desc. Ao
to reduce the “sand-blasting” effect

• If asc. Ao is totally calcified and rigid (so-called “porcelain” aorta)

No clamping of asc. Ao
Use of an alternate site for arterial cannulation
“Off-pump” Sx
Cannula design and choice
• The arterial cannula is usually the narrowest part of the ECC
• Narrowest portion  should be as short as compatible with safety
• Thereafter  size should enlarge to minimize the gradient
Long catheters with a uniform narrow diameter are undesirable
• Pressures gradients >100 mmHg are associated with excessive hemolysis
and protein denaturation
Select a cannula  provides adequate flow with a gradient no >100mmHg

Jetting effect produced by small cannulas  damages interior Ao wall, dislodge

atheroemboli (sandblasting) and cause arterial dissections, and disturb the flow the
flow into nearby vessels
Cannula design and choice
• Developments  allow the use of thin wall cannulae
By having a larger effective internal diameter, they achieve lower resistance to
flow
• Further developments  angled tip arterial cannulation
These manipulate the flow characteristics of blood leaving the cannula to
produce a spray effect, dispersing blood into the aorta
Minimizes damage to the vessel wall
Reduces pressure drop at the tip of cannula
Describe the cannula
• Tip: Short/Long; beveled/diffusion; straight/curved
• Single/2 cast
• Vented/non-vented
• Wire-reinforced/not
• Made from PVC/metal tip
• Sizes available – selection  based on flow required
Types of cannulae
• Right-angled  prevents perforating posterior wall of Ao  However – can
selectively perfuse an arch branch
• Straight prevents selective arch vessel perfusion  However – can
penetrate the posterior wall of the aorta.
• Beveled tip  easier insertion  however – has a higher pressure gradient
delivered at the tip
• Diffusion tip  less pressure gradient allows better perfusion of arch branches
 yet is slightly more difficult
• Wire reinforced  allows higher flow for a smaller size cannula and also
more immune to iatrogenic dissection
• Flanges  hemostatic as well as act as anchor points for the purse strings
Aortic cannulation technique
• 2 concentric purse-string sutures into Ao wall  choice of thickness
of bites
• Incise and dissect away the adventitia within the purse-string suture
• Partial occluding clamp  except in pediatric patients – minimize
clamp trauma to Ao
Optimal arterial blood pressure during cannulation (MAP ~70-
80mmHg, SBP ~100-120mmHg)
If too high  greater chance of tears and dissection, blood loss and spray
If too low  Ao tends to collapse, harder to make an incision and insert the
cannula, greater risk of damaging the back wall of Ao
Aortic cannulation technique
• An appropriately long full-thickness incision is then made  leak is
controlled
with a finger or
by approximating the adventitia or
by simultaneously inserting the cannula
• Dilators are sometimes used
• If a right-angled cannula tip is used, it is often initially directed toward the
heart and then rotated 180° to confirm intraluminal placement
• Brief vigorous back bleeding out of the open cannula is then allowed to
eliminate air or atheromatous debris and to further confirm intraluminal
placement
Aortic cannulation technique
• Insert only 1-2 cm of the tip into Ao and direct it toward the middle of
the transverse arch to avoid entering the arch vessels
• Others have advocated threading a long cannula into the proximal
descending aorta to reduce the velocity and turbulence in the arch to
reduce the “sand-blast” effect and emboli
Although atheromata may be dislodged by the act of inserting this cannula
through the intervening thoracic aorta
• After insertion  test infusion with systemic pump through arterial
line before initiating CPB – regardless of location of arterial cannula
A higher-than-expected pressure in the circuit arterial line warns of possible
dissection and may help avoid a more extensive dissection
Complications
1. Inability to introduce the cannula (interference by adventitia or plaques, too small an incision,
fibrosis of the wall, low arterial pressure)
2. Intramural placement
3. Dislodgment of atheroemboli
4. Air embolism from the cannula
5. Injury to the back wall of Ao
6. Persistent bleeding around the cannula or at the site after its removal
7. Malposition of the tip
8. Abnormal cerebral perfusion
9. Obstruction of Ao in infants
10. Ao dissection
11. High CPB arterial-side line pressure
12. False aneurysms
High CPB circuit arterial-line pressure
• Malposition of the tip against the vessel wall or into an arch vessel
• Cannula occlusion by the aortic cross-clamp
• Ao dissection
• Kink in the inflow system
• An arterial-line clamp that is still on
• Use of too small a cannula for the intended CPB flow
False aneurysms
• Late complications of aortic cannulation
• May rupture or become infected
• Arterial cannulation site was found to be the source of ~1/3 rd asc. Ao
aneurysms that follow cardiac surgery
Of which ~40% were infected
Mortality of such complications was ~50%
Femoral artery cannulation (or Iliac)
• Exposed through a suprainguinal approach
• Indications:
Aneurysm of asc. Ao or when it is otherwise unsatisfactory for cannulation
Inadequate space available due to multiple procedures involving the asc. Ao
Peripheral cannulation under LA in unstable patients
During re-operations prophylactically, when bleeding complications occur during
reentry
When an antegrade dissection complicates aortic cannulation
• Requires a second incision and limits the size of the cannula that can be used
Hence – adverse consequences of fluid jetting effects and high pressure gradients are
more likely
Complications
• Trauma to the cannulated vessel  tears, dissection, late stenosis or
thrombosis, and bleeding; lymph fistula; infection; embolization; and
limb ischemia
• Ischemic complications  acidosis, compartment syndrome, muscle
necrosis, and neuropathy – may develop if cannulation >3-6 hours
• The most serious complication  retrograde arterial dissection 
leads to retroperitoneal hemorrhage or retrograde dissection extension
all the way to Ao root
Subclavian/Axillary artery cannulation
• Use of the axillary artery (either by direct cannulation or through an attached 8-
mm graft)
• During a left thoracotomy  intrathoracic subclavian artery may be cannulated
• Advantages of the axillary artery over the femoral artery:
Lower likelihood of atherosclerosis
Better collateral flow with lower risk of ischemic complications
Better healing with fewer wound complications
• Axillary artery cannulation for type A Ao dissections
Less likely to result in malperfusion and further expansion of the dissection, as may occur
with femoral arterial perfusion
however, the absence of subclavian artery stenosis should first be documented by
comparing noninvasive or invasive arterial pressure in each arm before choosing this route
Technique
• Axillary artery is approached through a 4- to 10-cm incision below
and parallel to lateral 2/3rd of clavicle, or in deltopectoral groove
• Care must be taken to avoid traction on the brachial plexus
• Axillary vein is retracted away from artery (but may be used for
venous cannulation)
• A purse-string suture may then be placed in the axillary artery and a
20-22F right-angled or flexible arterial cannula is inserted in a
retrograde direction 2-3 cm
• In this circumstance  contralateral radial or brachial artery (usually
the left) must be used for intra-arterial pressure monitoring
Complications
• Axillary artery injury, thrombosis, or dissection
• Brachial plexus injury, new aortic dissection, malperfusion and
ischemia or compression syndrome

Important to monitor for malperfusion regardless of the vessel chosen

for arterial cannulation
Monitor bilateral radial artery pressures
Use of TEE (size of the true lumen and flow into the arch vessels)
Palpation of Ao
Innominate artery cannulation
• Instead of the axillary artery  eliminates need for a second incision
• Sewing an 8-10mm vascular graft end-to-side 4-5cm distal to its origin
while the artery is partially side-clamped and then inserting the
arterial-line cannula into this graft
• Cannula can also be inserted directly into the innominate artery
through a purse-string suture
Common carotid artery cannulation
• Left common carotid artery (LCCA) during surgery on desc. thoracic
Ao through a left posterior thoracotomy
• Approached through the neck, and an 8mm graft sutured onto it end-
to-side, into which a 22F cannula is inserted
Left ventricular apex
• Antegrade Ao perfusion can be accomplished by cannulating through
LV apex and passing the cannula (19-28F) across AoV into Ao root
• 7-mm cannula with a stylet through a 1cm incision in LV apex without
a purse-string suture
• Cannula is passed across AoV and tip positioned at the level of the
STJ and in the true lumen utilizing TEE guidance
Some questions
Q. Cannula pushed too deep?
Selective cannulation, abuts posterior wall

Q. Directed towards descending Aorta?

Particulate and gaseous matter towards branches of desc rather than CNS vessels

Q. Site of Aortic cannulation

Proximal to take off of innominate artery

Q. Adjustable collar?
Right length of cannula tip is inside