Semin cardiothorac vasc anesth

Upper hemisternotomy

Right anterior mini-thoracotomy 

(second or third ICS)

Right anterolateral 

minithoracotomy  

(fourth ICS)

Right anterolateral 

minithoracotomy  

(fourth ICS)

 

Lower hemisternotomy

Lower hemisternotomy

Arterial cannulation

Ascending aorta

Femoral artery

Femoral artery

 

Femoral artery

Ascending aorta

Ascending aorta

 

Axillary artery

Axillary artery

Axillary artery

Venous cannulation

Right atrium

Femoral vein

Femoral vein and RIJ/SVC

 

Femoral vein

(Also RIJ/SVC in concomitant 

RA procedures)

Abbreviations: ASD, atrial septal defect; ICS, intercostal space; RIJ, right internal jugular vein; SVC, superior vena cava; RA, right atrium.

a

Bold script represents our preferred site/approach.

 at UNIV MASSACHUSETTS BOSTON on August 28, 2014

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Shann and Melnitchouk 

149

non-ECG-gated CT angiography of the abdomen and pel-

vis in all patients undergoing minimally invasive mitral 

valve repair. This allows us to screen the majority of 

patients for coronary artery disease, evaluate the presence 

of mitral annular calcification, rule out significant aortoil-

iac atherosclerosis, and assess aortal dimensions with 1 

noninvasive test. Coronary angiography is then obtained 

as an adjunctive screening test in older patients and those 

with significant risk factors. Similarly, the group from 

Cleveland Clinic advocates for CT angiography in all 

patients undergoing minimally invasive robotic mitral 

valve surgery because aortoiliac atherosclerosis and/or 

mitral annular calcification has changed their operative 

strategy in 20% of screened patients, albeit the majority of 

that quintile’s patients were older and had other risk 

factors.

38

The axillary artery can be used for arterial access in situ-

ations where the femoral approach is prohibitive because of 

atherosclerosis or tortuosity. In addition, the axillary has 

also been used for minimal access ascending and aortic 

arch surgery through an upper hemisternotomy.

39

There are arterial cannulas that have been designed pri-

marily for minimally invasive cardiac valve surgery. 

ThruPort Systems (Edwards Lifesciences; Irvine, CA) is a 

system of minimally invasive cannulas (http://www.

edwards.com/Products/MIVS/Pages/MIVS.aspx) that are 

designed to facilitate minimally invasive intracardiac pro-

cedures. ThruPort commonly utilizes the EndoReturn fem-

oral artery cannula that is inserted under direct vision 

using the Seldinger technique. For isolated mitral valve 

procedures, the IntraClude catheter can also be used to 

facilitate endovascular aortic cross-clamping, cardioplegia 

delivery, and aortic root venting. The IntraClude is inserted 

through a side arm of the EndoReturn cannula and 

advanced into the ascending aorta under transesophageal 

echocardiogram (TEE) guidance.

The ascending aorta can be cannulated for minimally 

invasive procedures with a variety of cannulas that have 

been designed for ascending aortic cannulation. At our 

center, we use a small caliber (7 mm) wire-reinforced dif-

fusion cannula. There are other arterial cannulas, such as 

the Fem-Flex II (Edwards Lifesciences, Irvine, CA) and 

Bio-Medicus (Medtronic, Minneapolis, MN), that are 

designed for percutaneous femoral arterial cannulation 

using a modified Seldinger technique. Tables 2 and 3 pro-

vide reference values for the arterial cannula options we 

utilize.

In addition, the axillary artery can be cannulated utiliz-

ing the graft interposition technique and sewing a 8-mm 

Gore-Tex graft end-to-side to the artery and then inserting 

a ¼″ × 3/8″ connector into the graft. The graft is secured to 

the connector with heavy sutures or umbilical tape. In 

summary, we recommend the following strategies for arte-

rial cannulation during minimally invasive procedures:

•

• surgical procedure and patient disease characteris-

tics will dictate the site of arterial cannulation and

•

• when considering femoral arterial cannulation, CT 

angiography should be utilized to screen patients at 

risk for aortoiliac atherosclerosis.