Technical Consideration in Arteral Cannulation for Thoracic Aortic Surgery

1. Technical Consideration in ArteralCannulationfor Thoracic Aortic Surgery KittiyaKhwanmaung Prasitchai Udompornpaiboon Mongkol Nuanthong Ekachai Juiprasert Nattapong Chumpol Naraksak Vanbouas Wachiraporn Noinueay Arpa Arphaphongphatthara Yuppadee Prasansombut Witsanee Chokpaisan Perfusionist, Siriraj hospital

2. Aortic Disease Aortic aneurysm An Aortic aneurysm is a general term for any dilatation of the aorta to greater than 1.5 times normal usually representing an underlying weakness in the wall of the aorta at that location.

3. Aortic dissection Degeneration of medial layer is considered to be chief predisposing factor in nontraumatic dissection.

4. The surgical treatment for most aortic disease require cardiopulmonary bypass with various cannulation. Choosing the proper cannulating site for arterial return is an important point during the conduct of cardiopulmonary bypass .

5. SITE Cannulation sites • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Left ventricle apex

6. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

7. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

8. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

9. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

11. Operations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

12. Innominate artery cannulation Advantage :Antegrade cerebral perfusion DOI: 10.1016/j.athoracsur.2008.03.044 - The ascending aorta is the usual site of arterial inflow for CPB. When disease involves the ascending aorta or the aortic arch, or in some redo cases, the ascending aortic canulation is unavailable.

13. Innominate artery cannulation Head

14. Innominate artery cannulation Cannula : Soft flow : angle 6.0 mm, 7.0 mm Size of Metal tip : 4.5 mm, 5.0 mm

15. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

16. Axillary artery cannulation Advantage :- Antergrade cerebral perfusion - Safe and reliable (Axillary artery cannulation is safe and reliable in patients with ascending aortic disease.) DOI: 10.1016/j.athoracsur.2006.10.068 - The axillary artery was used as a second choice when no other cannulation site seemed to be suitable for perfusion.

17. Axillary artery cannulation

18. Axillary artery cannulation • Elongated One-Piece Arterial cannular; EOPA : 22 Fr. • 8 mm prosthetic side graft anastomosed to the axillary artery.

19. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

20. Ascending aorta cannulation Advantage : Simple aortic cannulation is safe, easy and reproducible. Head

21. Ascending aorta cannulation Canulars -------------------------- Size of Metal tip : 4.5 mm, 5.0 mm -------------------------- Soft flow : angle 6.0 mm, 7.0 mm -------------------------- -------------------------- Select cap: 18 Fr., 20 Fr. -------------------------- Soft flow : 6.0 mm, 7.0 mm --------------------------

22. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

23. Arch of aorta Advantage : We can cannulate above the assending aorta at arch of aorta.

24. Arch of aorta Canular -------------------------- Size of Metal tip : 4.5 mm, 5.0 mm -------------------------- Soft flow : angle 6.0 mm, 7.0 mm -------------------------- -------------------------- Select cap: 18 Fr., 20 Fr. -------------------------- Soft flow : 6.0 mm, 7.0 mm --------------------------

26. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

27. Femoral arterycannulation Advantage : Easy, fast doi: 10.1161/CIRCULATIONAHA.108.844480 - The femoral artery has been the standard cannulation site for cardiopulmonary bypass in treating acute aortic dissection type A.

28. Femoral arterycannulation

29. Femoral arterycannulation • Femoral artery cannula : 15 Fr., 17 Fr., 19 Fr., 21 Fr. • Femoral insertion kit

31. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

32. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

33. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

34. Side branch of the prosthesis graft cannulation Advantage : Reduced ischemia time lower body Head

35. Side branch of the prosthesis graft cannulation • Elongated One-Piece Arterial cannular (EOPA) : 22 Fr. • Graft 4 Branch plexus : 10/8/8 x 8 mm.

36. Direct to the prosthesis graftcannulation

37. Direct to the prosthesis graftcannulation Cannula - Elongated One-Piece Arterial cannular; EOPA : 18 Fr., 20 Fr., 22 Fr., 24 Fr.

39. Locations • Innominate artery • Axillary artery • Ascending aorta • Arch of aorta • Descending aorta • Femoral artery • Side branch of the prosthesis graft • Direct to the prosthesis graft • Apical

40. Transapical aortic canulation Advantage : - Simple and quick cannulation technique - Sufficient antergrade blood flow DOI: 10.1016/j.jtcvs.2006.04.016 - Axillary artery cannulation is a good and useful method but is not always safe or reliable in the presence of acute aortic dissection. In contrast, transapical aortic cannulation has the advantage of avoiding these problems, such as antegrade blood stream, and involves a simpler and quicker cannulation technique.

41. Transapical aortic canulation

42. Transapical aortic canulation Cannula - Elongated One-Piece Arterial cannular; EOPA : 18 Fr., 20 Fr., 22 Fr., 24 Fr.

43. Cannulation can be perform at many sites, but it depends on the pathology of patient and surgeon preference . It the preferred cannulation sites ware to the operation. It will help the operation going on conveniently , which could provide more chance to be success.

44. Than you