I was recently asked by a surgeon if I thought it was necessary to directly cannulate the axillary artery with a Biomedicus cannula and perform an angiogram when the most accepted way is to place a side graft on the axillary artery and just perfuse. My response was,” if this is what you are comfortable with, then this is the technique that you should use.” Well on second thought, I do think that you should probably at least do an intra-operative angiogram on everyone that you perform axillary cannulation. If you look at the intraop angio that I demonstrate here, one can see that the axillary and subclavian artery are free of disease, but there is a total occlusion of the innominate artery. I know that you are probably thinking that the artery look dissected, but I assure you that it is not. The cannula was placed under direct vision. I no longer use a Seldinger technique to cannulate the axillary artery. I believe that there is a significant potential to damage this very fragile and delicate artery. Therefore, I have resorted to obtaining proximal and distal control of the artery and perform a direct cutdown prior to inserting the cannula which has the guidewire back loaded into it. Antegrade perfusion with a side graft in this case would have proven to be fatal. 
Posted in Aortic Valve Surgery, Ascending Aorta, Mitral Valve Surgery
I asked the question. I suspect you could have perfused this patient because of collateral a, but who knows. I have 300 plus axillary cases without a problem, many for dissection but mostly diseased aortas. I believe wire utilization for cannulation increases stroke risk which was the genesis of my question. Obviously I hav no data since I’ve never done an angiogram. If perfusion pressures were high at onset, I might have to reconsider femoral(which I never do as first option) or getting an angiogram. There must have been an obstruction or two in my series given the majority of cases hav been for porcelain aortas, but no definitive data. Your thoughts?
You may be right about being able to perfuse but there may be a higher resistance to flow. I routinely utilize a guidewire and perform subclavian angio’s to verify that there is no contraindication to antegrade flow. I have had difficulty passing the wire into the aorta due to plaque in the innominate and have had to use a Versacore Floppy wire to cross the lesion. I thereafter pass a long introducer over the floppy wire and exchange the wire for a stiffer one which will allow me to cannulate. Despite all this manipulation, I have not had strokes in this group. The technique that you use is used successfully by many surgeons so therefore is proven and effective. I would not change what has worked for you.