You were all right. That is the tip of the arterial cannula which was placed from the axillary artery. The patient was placed on circulatory arrest. I have enclosed pictures to show the final result.
I use axillary cannulation as my 2nd access site of choice. My first is obviously femoral. We have a paper submitted to the Journal of Heart Valve Disease on the incidence of strokes in patients where femoral cannulation is used. In over 1,000 patients, all risk categories, the incidence was 1.2%. I truly believe that strokes occur more from particulate matter, debris and air. It is not the cannulation.
When I cannulate the axillary artery, I will make a 2 cm skin incision 1 cm beneath the clavicle and just medial to the delto-pectoral groove. I will bovie through the pectoralis muscle. It is very difficult to feel a great pulse in the axillary artery. But once you feel it, you continue to dissect the tissues until you find it. The artery is usually superior and inferior to the vein. I have rarely found an axillary artery that is diseased enough that it cannot be cannulated (even when there is severe PVD). In one case I did and I had to go to the left axillary artery. I then obtain proximal and distal control of the vessel with silastic vessel loops. I will pull on the distal loop and will clamp the proximal aspect of the artery with a vascular clamp. I perform a direct arteriotomy on the vessel, back load the Biomedicus cannula with a wire, introduce the tip of the cannula and then advance the wire. I initially identify the wire on the TEE. It will usually be seen in the ascending aorta. I will then advance the cannula over the wire. I almost always confirm placement and location with an angiogram on the table. I usually use flouroscopy to advance the cannula as well. I have a video on my blog which demonstrates axillary cannulation. In this video, I use a Seldinger technique to cannulate the axillary artery. I have since abandoned this approach and use a direct arteriotomy and advance the cannula. The reason for this is because I have damaged a few axillary arteries and have had to repair some with patches and even one with an interposition graft.
Axillary cannulation is a technique that needs to be in everyone’s armamentarium. It not simple and does take longer than femoral cannulation. And no, I do not place a side graft on the axillary artery.
Another tip is that if you cannulate the axillary artery, you can usually use a cannula that is one size smaller than the one needed for femoral cannulation. I think that when the cannula is placed centrally (axillary) the perfusionist do not have a problem with the smaller size.
I use a the following sizes for femoral cannulation:
BSA CANNULA SIZE (Biomedicus)
<1.6 15 Fr.
1.7 -2.1 17 Fr.