Semin cardiothorac vasc anesth

Table 2.  Ascending Aortic Cannula, Estimated Flow Rates.

BSA

Size

Maximum Flow 

(L/min)

Model

Manufacturer

≤2.0 m

2

6.0 mm

4.8

Soft-Flow

Terumo

>2.0 m

2

 to <2.5 m

2

7.0 mm

6.0

Soft-Flow

Terumo

≥2.5 m

2

8.0 mm

8.0

Soft-Flow

Terumo

Abbreviations: BSA, Body Surface Area

Table 3.  Femoral Artery Cannula, Estimated Flow Rates.

BSA

Size

Maximum 

Flow (L/min)

Model

Manufacturer

≤1.3 m

2

15 Fr

2.5

Bio-Medicus Medtronic

≤1.3 m

2

16 Fr

3.2

Fem-Flex

Edwards Life 

Science

1.3 m

2

 to 1.7 m

2

17 Fr

4.0

Bio-Medicus Medtronic

1.3 m

2

 to 1.9 m

2

18 Fr

4.6

Fem-Flex

Edwards Life 

Science

1.9 m

2

 to 2.2 m

2

19 Fr

5.3

Bio-Medicus Medtronic

>1.9 m

2

20 Fr

6.0

Fem-Flex

Edwards Life 

Science

>2.2 m

2

21 Fr

6.0

Bio-Medicus Medtronic

 at UNIV MASSACHUSETTS BOSTON on August 28, 2014

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150 

Seminars in Cardiothoracic and Vascular Anesthesia 18(2)

placed in the RIJ vein (the distal one for the PA catheter 

sheath and the more proximal one for the neck cannula). A 

bolus of 5000 units of heparin is administered, and using the 

Seldinger technique with serial dilation to appropriate diam-

eter, a 15-, 17-, or 19-Fr Bio-Medicus femoral arterial can-

nula is placed and advanced to the RA/SVC junction with 

TEE guidance. If the RIJ vein is measured on ultrasound to 

be larger than 1 cm, a 17- or 19-Fr cannula is commonly 

utilized. After RIJ cannula insertion, heparinized saline is 

infused slowly (5000 units of heparin in 1000 mL of normal 

saline) via the leur port on the cannula until full hepariniza-

tion for CPB occurs. The RIJ cannula is connected to the 

CPB circuit via a split venous line and clamped. This clamp 

is removed by the perfusionist at the initiation of CPB and 

clamped by the perfusionist at the commencement of CPB. 

Because this line is typically routed outside the surgical field, 

teams are encouraged to be vigilant with the management of 

this line to avoid unintentional venous drainage before or 

after CPB. The RIJ cannula is removed at the end of the pro-

cedure, the purse string on the skin is tied, and pressure is 

applied for 15 minutes.

QuickDraw (Edwards Lifesciences; Irvine, CA) femo-

ral venous cannulas are designed with multiple drainage 

holes to facilitate the ThruPort procedure but can be used 

for other minimally invasive procedures as well. The 

Remote Access Perfusion (Sorin Group Italia, Mirandola, 

Italy) femoral venous cannulas have a bicaval multiple 

drainage hole design, can be inserted percutaneously, have 

excellent flow characteristics, and have become our pre-

ferred cannula. These cannulas are commonly inserted in 

the femoral vein under direct vision using the modified 

Seldinger technique. They are also long enough (65 cm) to 

be advanced into the SVC to facilitate bicaval single-can-

nula drainage. Tables 4 and 5 provide reference values for 

the venous cannula options we utilize.

There are other femoral venous cannulas that have been 

designed to facilitate peripheral CPB and can be used for 

minimally invasive cardiac surgery, including the Fem-Flex 

II and Bio-Medicus. Depending on the size of the cannula, 

they can be placed percutaneously or under direct vision. It 

is common practice at our center to perform all femoral can-

nulation under direct vision over an Amplatz Super Stiff 

J-Tip guidewire (Boston Scientific Corp, Natick, MA).

In summary, we recommend the following strategies for 

venous cannulation during minimally invasive procedures:

•

• surgical procedure and patient disease characteris-

tics will dictate the site of arterial cannulation;

•

• our preference is to use the 23/25Fr RAP cannula 

for all femoral venous cannulations;

•

• an IJ venous cannula (15-, 17-, 19-Fr Bio-Medicus 

femoral arterial) should be used for right-sided pro-

cedures and in patients >80 kg having mitral valve 

procedures; and

•

• a protocol for safely managing the venous line con-

nected to the IJ cannula should be developed; the IJ 

is commonly cannulated and connected to the 

venous line outside of the surgical field.