Axillary Cannulation in Minimally Invasive Cardiac Surgery

Surgical exposure and cannulation of the femoral artery and vein is the standard approach for connection to the extracorporeal circulation in minimally invasive valve surgery. There are, however, potential downsides, such as the retrograde direction of arterial perfusion and the potential for local inguinal complications, such as lymphorrhea, irritation of the femoral nerve, or infection. In this short video, the authors present an alternative strategy: limited surgical exposure and direct cannulation of the right axillary artery, percutaneous puncture of the femoral vein, and cannulation of the right atrium with a long, two-stage venous cannula. The right axillary artery and right femoral vein are identified by means of ultrasound and marked on the skin. Surgical exposure and isolation of the right axillary artery is performed through a limited skin incision 3 cm in length. A purse string suture (4-0 polypropylene) is placed, and heparin is administered (target activated clotting time >450 s). The right axillary artery is punctured and a guide wire is introduced under echocardiographic monitoring. Progressive dilatation is performed and cannulation is achieved with a straight wire-reinforced cannula over the guidewire. Next, sonographically-assisted percutaneous puncture of the femoral vein is performed. A long guide wire is guided well into the superior vena cava using echocardiography. Progressive dilatation is performed. The right atrium is cannulated under echocardiographic guidance with a long two-stage wire-reinforced venous cannula placed over the guidewire. The cephalad opening of the cannula must enter the superior vena cava for adequate venous drainage. Suggested Reading 1. Lamelas J, Williams RF, Mawad M, LaPietra A. Complications associated with femoral cannulation during minimally invasive cardiac surgery. Ann Thorac Surg. 2017;103(6):1927-1932. 2. Murzi M, Cerillo AG, Miceli A, et al. Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral valve surgery: a propensity score analysis on 1280 patients. Eur J Cardiothorac Surg. 2013;43(6):e167-e172. 3. Gammie JS, Zhao Y, Peterson ED, O’Brien SM, Rankin JS, Griffith BP. J. Maxwell Chamberlain Memorial Paper for adult cardiac surgery. Less-invasive mitral valve operations: trends and outcomes from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2010;90(5):1401-1410.