Common Carotid Artery Cannulation: A Potential Alternative Site for Establishing CPB in Special Situations

2018-03-19T21:05:38Z (GMT) by Ishtiaque Al-Manzo Prasanta Chanda
<p>For establishing regular cardiopulmonary bypass, the ascending aorta is obviously the standard site of arterial cannulation, ensuring adequate blood supply to the whole body. However, when the aortic arch has to be replaced, finding a suitable arterial cannulation site becomes more challenging. <br></p><p>The femoral artery is an answer to this situation, and for a long period of time its cannulation was established as a routine practice. However, in a small number of patients, particularly those with aortic dissection, fatal complications like atheroembolism, malperfusion, ischemic complications, and even aortic rupture have been encountered. Moreover, total circulatory arrest is usually necessary during surgical correction involving the distal ascending aorta and the arch of the aorta. Unfortunately, systemic hypothermia and external cranial cooling alone cannot ensure adequate cerebral protection. Cerebral perfusion, preferably antegrade flow, along with hypothermia is a well-accepted and practiced technique, but requires some time to set up, mandating an interruption of cerebral blood flow. Therefore, identifying a suitable alternative site that can provide antegrade blood flow to the whole body, as well as maintaining cerebral perfusion, even at the time of arch exclusion or repair, is necessary.</p><p>Right axillary artery cannulation is practiced, but the procedure is time-consuming, with an increased risk of injury to neighboring structures, and it has limited efficiency of perfusion due to the artery’s narrow caliber. Use of the brachiocephalic artery ensures better perfusion, but has the risk of being involved in the arch pathology, which makes it prone to malperfusion and embolization.</p><p>In contrast, the common carotid artery is a potential alternative. It can be approached easily with a minimum risk of collateral injury due to its superficial anatomical location, and it is bilaterally available. It can provide antegrade blood flow to the entire body, and can also maintain cerebral perfusion during circulatory arrest without any interruption.</p><p>In this video, the authors demonstrate the procedure of cannulation of the right common carotid artery. The patient was a 17-year-old girl with a history of ventricular septal defect closure and patent ductus arteriosus ligation done 10 years previously. She presented with acute type A aortic dissection. Her right subclavian and right common carotid artery both were directly originating from the arch of the aorta. The right common carotid artery was the ideal option for arterial cannulation.</p><p>A 4 cm skin incision was made in the neck, along the medial border of the sternocleidomastoid muscle and 2 cm above its sternal insertion, extending toward the ear lobe. A self-retaining retractor was applied, the platysma muscle was dissected, and the right jugular vein was exposed just below the muscle. The vagus nerve was easily identified between the common carotid artery and the jugular vein. The right common carotid artery was dissected, and a vascular loop was passed around it. A side-biting clamp was placed, and an arteriotomy was created. A 10 mm vascular prosthesis was anastomosed end-to-side to the artery with a continuous 5.0 Prolene suture. The other end of the vascular prosthesis was tied to a connector and then attached to the arterial perfusion line. Venous cannulation was accomplished through the femoral vein.</p>