Iatrogenic pseudoaneurysm of the axillary artery: Prevention better than cure.
Anand Sachithanandan, Hospital Serdang
20 July 2011
I read with interest the excellent report by Mazzaccaro et al regarding successful ultrasound guided endovascular stent repair of an iatrogenic axillary artery pseudoaneurysm via the brachial route (1). Although the reported incidence of iatrogenic axillary artery false aneurysms is rare, it is likely such complications will increase in the future as axillary cannulation becomes increasingly popular in contemporary surgical practice for repair of ascending aorta and arch aneurysms or dissections, and for re-operative procedures.
The advantages of axillary cannulation are numerous and includes continous antegrade perfusion, obviates the need to re-position the arterial cannula from the femoral site at a later stage in the operation, reduces the risk of false lumen malperfusion and eliminates retrograde extension of a dissection flap. Axillary cannulation also facilitates reliable selective antegrade cerebral perfusion (SACP) for complex cases requiring deep hypothermic circulatory arrest (DHCA). However, given the relative surgical inaccessibility of the infraclavicular proximal axillary artery, direct cannulation of this vessel may result in a higher chance of late post-operative pseudoaneurysm formation. Furthermore iatrogenic axillary stenosis with compromised antegrade brachial blood flow and brachial plexus injury are more likely to occur with a direct technique.
A simple but useful technique is to perform a side to end anastomosis with a small tubular vascular graft onto the axillary artery with partial heparinisation and use of a small partial occlusion side biting clamp. The graft can then be cannulated and subsequently decannulated with relative ease. At the end of the procedure, the graft can be simply ligated and divided, leaving a small residual stump. The safety and efficacy of this technique which avoids direct cannulation of the vessel is well validated (2).
References
1. Mazzaccaro D, Malacrida G, Occhiuto MT, Stegher S, Tealdi DG, Giovanni N. Journal of Cardiothoracic Surgery 2011, 6:78 Ann Thorac Surg.2010 Sep;90(3):731-7.
2. Wong DR, Coselli JS, Palmero L, Bozinovski J, Carter SA, Murariu D, LeMaire SA. Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections. Ann Thorac Surg. 2010 Sep;90(3):731-7.
Iatrogenic pseudoaneurysm of the axillary artery: Prevention better than cure.
20 July 2011
I read with interest the excellent report by Mazzaccaro et al regarding successful ultrasound guided endovascular stent repair of an iatrogenic axillary artery pseudoaneurysm via the brachial route (1). Although the reported incidence of iatrogenic axillary artery false aneurysms is rare, it is likely such complications will increase in the future as axillary cannulation becomes increasingly popular in contemporary surgical practice for repair of ascending aorta and arch aneurysms or dissections, and for re-operative procedures.
The advantages of axillary cannulation are numerous and includes continous antegrade perfusion, obviates the need to re-position the arterial cannula from the femoral site at a later stage in the operation, reduces the risk of false lumen malperfusion and eliminates retrograde extension of a dissection flap. Axillary cannulation also facilitates reliable selective antegrade cerebral perfusion (SACP) for complex cases requiring deep hypothermic circulatory arrest (DHCA). However, given the relative surgical inaccessibility of the infraclavicular proximal axillary artery, direct cannulation of this vessel may result in a higher chance of late post-operative pseudoaneurysm formation. Furthermore iatrogenic axillary stenosis with compromised antegrade brachial blood flow and brachial plexus injury are more likely to occur with a direct technique.
A simple but useful technique is to perform a side to end anastomosis with a small tubular vascular graft onto the axillary artery with partial heparinisation and use of a small partial occlusion side biting clamp. The graft can then be cannulated and subsequently decannulated with relative ease. At the end of the procedure, the graft can be simply ligated and divided, leaving a small residual stump. The safety and efficacy of this technique which avoids direct cannulation of the vessel is well validated (2).
References
1. Mazzaccaro D, Malacrida G, Occhiuto MT, Stegher S, Tealdi DG, Giovanni N. Journal of Cardiothoracic Surgery 2011, 6:78 Ann Thorac Surg.2010 Sep;90(3):731-7.
2. Wong DR, Coselli JS, Palmero L, Bozinovski J, Carter SA, Murariu D, LeMaire SA. Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections. Ann Thorac Surg. 2010 Sep;90(3):731-7.
Competing interests
None to declare