What are the steps for an operative axillary cutdown for cardiac bypass during Aortic Valve (AV) replacement?

From the Guidelines

Axillary artery cutdown for cardiac bypass during aortic valve replacement is a valuable approach when peripheral vascular disease precludes femoral cannulation, and the procedure should be performed with careful attention to detail to minimize potential complications, as supported by the most recent guidelines 1. The procedure begins with positioning the patient supine with the arm abducted to 90 degrees. After standard sterile preparation, a 5-7 cm incision is made 2 cm below the clavicle, parallel to the deltopectoral groove. The pectoralis major and minor muscles are divided or retracted to expose the neurovascular bundle. The axillary artery is carefully identified and isolated from surrounding structures, particularly the brachial plexus. Two vessel loops are placed around the artery for control. Some key considerations for the procedure include:

• Patient positioning to improve access to the anterior axillary line, as described in a study on minimally invasive mitral valve surgery 1
• The use of a small pillow or IV bag to open up the axillary space, as noted in the same study 1
• The importance of careful technique to minimize potential complications, including brachial plexus injury, lymphatic leakage, and upper extremity ischemia After systemic heparinization (300-400 units/kg to achieve ACT >480 seconds), the artery is partially clamped, and an arteriotomy is created. An 8-10 mm Dacron or PTFE graft is anastomosed to the artery using 5-0 or 6-0 polypropylene suture in an end-to-side fashion. The graft is then connected to the arterial line of the cardiopulmonary bypass circuit. This approach provides reliable arterial inflow during bypass, reduces risk of retrograde embolization compared to femoral cannulation, and allows antegrade perfusion to the brain during circulatory arrest if needed, as discussed in the context of transcatheter aortic valve replacement 1. The procedure should be guided by the most recent and highest quality evidence, with consideration of individual patient factors and the potential benefits and risks of the approach, as emphasized in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.

From the Research

Operative Axillary Cutdown for Cardiac Bypass during AV Replacement

The steps for operative axillary cutdown for cardiac bypass during AV replacement involve several key considerations, including:

• Selection of the appropriate axillary artery for cannulation, with the right axillary artery being the most commonly used 2, 3
• Creation of a side graft for axillary artery cannulation, which provides sufficient antegrade aortic flow during cardiopulmonary bypass 3
• Use of the axillary artery conduit for arterial access during transapical transcatheter aortic valve replacement, which can be a safe and effective alternative to traditional access routes 4
• Consideration of the patient's peripheral vascular disease and aortic disease, as these factors can impact the choice of cannulation site and the risk of complications 5, 6

Key Considerations

Some key considerations for operative axillary cutdown for cardiac bypass during AV replacement include:

• The need for careful patient selection and evaluation of the axillary artery anatomy and peripheral vascular disease 6, 3
• The importance of proper surgical technique and cannulation methods to minimize the risk of complications, such as stroke or wound infection 2, 3
• The potential benefits of using the axillary artery for cannulation, including reduced risk of embolic events and improved perfusion during cardiopulmonary bypass 5, 2

Surgical Techniques

The surgical techniques used for operative axillary cutdown for cardiac bypass during AV replacement may vary depending on the specific patient and procedure, but may include:

• Direct cannulation of the axillary artery 2
• Creation of a side graft for axillary artery cannulation 3
• Use of an axillary artery conduit for arterial access during transapical transcatheter aortic valve replacement 4
• Closure of the axillary artery and graft sites to prevent complications, such as bleeding or infection 5, 2