Reliability of axillary artery cannulation

We read with interest the article by Urbanski et al. [1] about the cannulation of arch arteries for hostile aorta. For ascending and aortic arch repair, we prefer right axillary artery (AxA) cannulation similar to the aforementioned article. There are really very few contraindications to AxA cannulation. We would like to remind another important contraindication to AxA cannulation.

A 70-year-old man was admitted to our clinic for type 1 acute aortic dissection. His general condition was poor, and emergency operation was planned. The right AxA was cannulated and proximal aortic anastomosis was performed after cross-clamping the ascending aorta below innominate artery. We decided to perform open distal anastomosis and clamped the innominate artery and left common carotid artery and began antegrade cerebral perfusion with 10 ml/kg with moderate hypothermia. We immediately realized that excessive blood was coming from the descending aorta, and bispectral index monitoring showed reduction more than expected. When we explored, we found that there was a fourth vessel in the descending aorta and all the blood was coming from there. We changed the arterial line to the left common carotid artery without any delay. Everything returned normal after that and the patient had an uneventful recovery.

Aberrant right subclavian artery (ARSA) or arteria lusoria is the most common congenital abnormality of the aortic arch and is present in 0.6–1.4% of individuals [2]. It typically remains asymptomatic. ARSA is an anatomic variation that originates from the proximal descending aorta. AxA cannulation in the presence of ARSA causes no brain perfusion during the whole procedure and inflow routes to the descending aorta [3]. If poor cerebral perfusion is detected despite everything seems normal, ARSA should come to mind and an alternative cannulation site like pro common carotid artery cannulation as mentioned in the article must be preferred immediately.

As a conclusion, comprehensive evaluation of arch arteries should be done preoperatively, and the ideal arterial cannulation sites should be decided individually for each patient.

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