Direct Axillary Artery Cannulation: Safe, Expeditious, and Hemostatic
The right axillary artery (AX) has been the authors’ standard cannulation site for elective aortic arch repair, acute aortic dissection repair, or complex redo aortic or cardiac cases. (1,2)
To begin the procedure, a 4-5 cm transverse skin incision is made approximately 1 cm below the middle and lateral part of the right clavicle (deltopectoral groove). The subcutaneous tissue and pectoralis major muscle are then divided using an electrocautery. After further dissection, the pectoralis minor muscle is retracted outward using a Henley self-retaining retractor. The artery is then controlled with loops of silicone elastomer tape, which are then passed through a red rubber. It is important to retract the distal AX by vessel loops to make a “slope,” which facilitates direct AX cannulation technique, especially in patients with a deep anatomy.
Next, the proximal AX is clamped and the AX is incised transversely and directly cannulated with care to insert the cannula less than 3 cm (2). Currently, a straight cannula is used for direct AX cannulation technique. In most cases, either 18 or 20 Fr are sufficient to provide full cardiopulmonary bypass flow with excellent line pressure. A 16 Fr cannula can be used in small patients. In aortic dissection cases or patients with fragile AX, care should be taken when inserting a cannula. In this regard, Edwards Optisite cannula facilitates direct AX cannulation technique, as it has an inner dilator which also allows use of the Seldinger technique instead of transverse incision technique (2).
Next in the procedure, the proximal silicone tape with a red rubber is tightened and secured to the cannula. It is important to confirm sufficient back bleeding from an arterial cannula. The arterial cannula is then connected to an arterial line of cardiopulmonary bypass. In all cases, the AX cannula is removed before giving protamine sulfate. The cannulation site is primarily repaired with 6-0 polypropylene sutures.
In redo AX cannulation cases, a similar approach can be applied if previous cannulation used the direct cannulation technique. Either proximal or distal to the previous cannulation site can be used. Care should be taken not to injure the brachial plexus as anatomy is not always as same as primary AX cannulation cases. In case of previous AX cannulation using a side graft technique, the direct cannulation technique can be used proximal to the old side graft, or the side graft can be anastomosed to the old graft after trimming the graft as short as possible (3).
A major concern for the direct cannulation technique is the potential for vascular injury and iatrogenic dissection from AX cannulation. A study documents that vascular injury and iatrogenic dissection are quite rare—respectively 1.0 percent and 0.2 percent overall and only 0.4 percent and 0.4 percent for non-dissection cases (1). Of note, AX injury can happen even using the side graft technique secondary to clamping the artery or relating to the graft anastomosis.
Puiu et al. demonstrated that the side graft technique required more packed red blood cells than the direct cannulation technique (4). As many surgeons have experienced, there is significant leakage from the anastomosis during cardiopulmonary bypass when using the side graft technique. In addition, hyperperfusion to the ipsilateral arm often happens, which may need adjustment of flow distal to the anastomosis in the side graft technique, while direct AX cannulation technique does not require this. The authors have not experienced any arm ischemia based on more than 500 aortic cases using the direct AX cannulation technique (1).
In conclusion, potential benefits of direct axillary artery cannulation technique over side-graft technique include expediency, less bleeding during cardiopulmonary bypass, no need to control distal flow in the ipsilateral arm, and no foreign body left at the completion of the procedure.