Minimally invasive cardiac surgery (MICS) frequently requires peripheral cannulation strategies. Femoral cannulation remains the standard approach; however, it is associated with potential complications such as lymphorrhea, hematoma, infection, and an increased risk of embolic stroke in patients with significant atherosclerotic burden due to retrograde perfusion during cardiopulmonary bypass (CPB) (1, 2).
Axillary artery cannulation represents an important alternative, particularly for achieving antegrade systemic perfusion during CPB. Most studies addressing cannulation techniques in MICS predominantly focus on minimally invasive mitral valve surgery. In most of these series, femoral vessels are the preferred cannulation site, largely influenced by institutional practice. However, patient populations differ significantly in terms of atherosclerotic burden, particularly between those undergoing coronary artery bypass grafting (CABG) and those undergoing isolated valvular procedures.
Patients with coronary artery disease tend to have a higher degree of peripheral atherosclerosis compared to patients with isolated valve disease. With the increasing adoption of minimally invasive coronary surgery, complications related to cannulation site selection may be underreported in the literature, especially in this high-risk subgroup.
This video demonstrates a standardized technique for direct axillary artery cannulation using an open Seldinger approach, which the authors routinely employ in patients undergoing MICS with evidence of peripheral arterial disease.
Ultrasound Guided Mapping and Cannula Size Selection
The axillary artery was examined with ultrasound in the infraclavicular region. The inner diameter of the axillary artery was measured, and the cannula size was selected based on the patient’s body surface area and the axillary artery diameter.
Surgical Exploration of the Axillary Artery
After sterile skin preparation and draping, the axillary artery was reexamined with ultrasound because the skin markings or the artery’s position could change after arm positioning and draping. The goal was to cannulate the axillary artery in the second segment, just proximal to the origin of the thoracoacromial artery. In this part, the nerves are mostly deeper to the artery, and the arterial diameter is larger than in distal segments.
A 3-4 cm skin incision was made. The fibers of the pectoralis major muscle were divided, and the pectoralis minor was retracted laterally with a second retractor if needed. The axillary artery was encircled with silicon tape, then retracted laterally and anteriorly. The target entry site on the axillary artery was marked, and a single purse-string suture was placed. A small Teflon pledget and a snare were placed to achieve hemostasis when needed. Before cannulation, the arterial cannula was flushed with carbon dioxide to prevent any air bubbles.
Cannulation With the Open Seldinger Technique
The axillary artery was punctured with a needle, and a J-tip guidewire was advanced through the artery. If the J-tip wire cannot be advanced through, a soft tip hydrophilic wire can be used. It is crucial to visualize the guidewire at the aortic root or descending aorta with transesophageal echocardiography (TEE) to avoid dissection or arterial injury. After gradual dilation of the entry site, the arterial cannula was advanced over the guidewire. Continuous verification of the guidewire position with TEE and maintaining appropriate wire tension during dilator and cannula advancement are essential to prevent arterial injury.
The cannula was advanced approximately 5-6 cm through the artery and meticulously de-aired. After backflow verification with declamping, the cannula was retracted approximately 1 cm and connected to the arterial line. The snare was tightened to prevent oozing, and the cannula was then fixated with sutures just lateral to the incision and at multiple points to prevent dislocation or kinking during the operation.
Decannulation
After termination of cardiopulmonary bypass, a retractor was placed and the vascular loop around the axillary artery was retracted laterally. The surgeon drew the cannula back slowly while the assistant tightened the purse string suture and maintained the hemostasis with the snare. A figure-of-eight suture was placed around the purse-string suture and tied. The purse-string suture was tied afterward, and the distal pulse was checked both manually and with ultrasound to confirm patent flow.
Conclusion
Minimally invasive cardiac surgery is being performed with increasing frequency, and its indications are expanding to include higher-risk patient populations. Axillary cannulation should be considered a primary cannulation strategy, particularly in patients with a significant atherosclerotic burden. This technique is safe, reproducible, and can be reliably applied even in reoperative cases. In patients with severe atherosclerosis of the right axillary or innominate artery, the left axillary artery may serve as an alternative cannulation site.
This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.
References
- Lamelas, J., Aberle, C., Macias, A. E., & Alnajar, A. (2020). Cannulation strategies for minimally invasive cardiac surgery. Innovations, 15(3), 261-269.
- Murzi, M., Cerillo, A. G., Gasbarri, T., Margaryan, R., Kallushi, E., Farneti, P., & Solinas, M. (2017). Antegrade and retrograde perfusion in minimally invasive mitral valve surgery with transthoracic aortic clamping: a single-institution experience with 1632 patients over 12 years. Interactive cardiovascular and thoracic surgery, 24(3), 363-368.
Disclaimer
The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.
979 views on Vimeo
