Tips and Pitfalls for Inferior Vena Cava Cannulation Via the Axillary Approach

Enlarging Axillary Incision 

The axillary incision was enlarged in two ways. First, a horizontal conversion to a posterolateral approach was performed based on previous pen markings. Additionally, a vertical downward enlargement was made to reach the selected chest drain location.  

Use of Right Atrial Appendage 

The right atrial appendage was utilized by placing a purse-string suture for traction, which allowed access to the ascending aorta. Furthermore, a large vent was inserted to aid in right atrium drainage prior to inferior vena cava (IVC) cannulation.  

IVC Cannula Through Right Appendage 

The IVC cannulation was performed through the right appendage by starting the extracorporeal circulation (ECC) with the cannula positioned in the mid-right atrium. The cannula was then slid downward until it entered the IVC, where it was secured with external tape.  

Encircling IVC 

To encircle the IVC, full flow was achieved on ECC, which decompressed the heart. A folded tape was grasped with a large curved clamp and slipped clockwise under the oblique sinus. Additionally, a deflactable shafted dissector was used in this process.  

Percutaneous IVC Cannulation  

For percutaneous IVC cannulation, which had been scheduled in advance, the patient was positioned horizontally with their hip rolled under the right arm. The anesthesiologist chased the femoral vein, ensuring that an introductor was in place. This technique is most effective if the left superior vena cava (LSVC) ispresent. It is critical to suspect inadvertent coronary sinus cannulation when there is poor drainage to the perfusionist, leading to abdominal congestion and an empty heart, along with air trapping upon opening the right atrium. 

Dislodged Cannula  

In the case of a dislodged cannula, whether accidental, with the tip in the coronary sinus, or causing air trapping, direct atriotomy cannulation is necessary. The IVC cannula was clamped and removed to prevent air trapping, and right IVC tape was applied. The atriotomy was then enlarged toward the IVC purse-string, allowing for direct cannulation of the IVC through the atriotomy, where the cannula was secured with snug tape. Full-flow was resumed, and the cannula was fastened to an external silk tape tourniquet.  

Late Removal 

For late removal, the closure of the atriotomy was started from the IVC corner, which pushed the cannula upward along the suture line. The cannula can become trapped between the upper corner and the suture line. It was then fastened either with the appendage or a tourniquet, if present, and the completion of the atriotomy closure occurred after the cannular was removed.

References

1. >3’000 Mini Thoracotomies from ECHSA for Quality Repairs of common Congenital Heart Defects: Safe, Routine, and Mature Enough for the New Training Curriculum? Dodge-Khatami A, Gil-Jaurena JM, Hörer J, Heinisch PP, Arrigoni SC, Cesnjevar RA et al. The EACTS 38th Annual Meeting. 9-12 October 2024, Lisbon (Portugal). World J Pediatr Congenit Heart Surg 2025;16(5):578-84. doi: 10.1177/21501351251322155.
2. Minimally Invasive Surgery for Congenital Heart Disease. Gupta S, McEwen C, Eqbal A, Haller C. Ann Thorac Surg 2024;118:953-63
3. Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects. Prêtre R, Kadner A, Dave H, Dodge-Khatami A, Bettax D, Berger F. J Thorac Cardiovasc Surg 2005;130:277-81
4. Minimally invasive surgery for atrial septal defects: a 20-year experience at a single centre. Vida VL, Zanotto L, Zanotto L, Tessari C, Padalino MA, Zanella F et al. Interact Cardiovasc Thorac Surg 2019;28:961-7.
5. Safety and efficacy of right axillary thoracotomy for repair of congenital heart defects in children. Said SM, Greathouse KC, McCarthy CM, Brown N, Kumar S, Salem MI et al. World J Pediatr Congenit Heart Surg 2023;14(1):47-54
6. How to set-up a program of minimally-invasive surgery for congenital heart defects. Gil-Jaurena JM, Pérez-Caballero R, Pita A, González-López MT, Sánchez J, De Agustín JC. Transl Pediatr 2016;5(3):125-33
7. Flexible Way to Encircle the Inferior Vena Cava in Minimally-Invasive Surgery. Gil-Jaurena JM, Pita A, De la Torre M. SM J Pediatr Surg 2018;4(3):1067
8. Developing new skills for smaller and hidden incisions. Gil-Jaurena JM, De Agustín JC, Valda C, Pita A, Pardo C, Pérez-Caballero R. J Surg Transplant Sci 2023:10(1):1088-91
9. Left axillary approach for pulmonary valve replacement. Gil-Jaurena JM, Pardo C, Pita A, Perez-Caballero R. MMCTS (18 Dic 2023) DOI: 10.1510/mmcts.2023.096
10. Minimally invasive congenital cardiac surgery. Gil-Jaurena JM, Pita A, Pardo C, Solís S, Díaz L, Pérez-Caballero R. Cir Cardiovasc 2025 (in press) doi:10.1016/j.circv.2025.05.004

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