Figure 3Axillary artery cannulation with sidearm graft. The axillary artery can be used when converting to an ambulatory configuration or when the femoral artery is unusable. Direct cannulation is possible, but patients may experience arm ischemia owing to occlusion of the vessel. Sidearm grafting resolves this issue, but it does leave a pressurized suture line that can lead to bleeding complications. Additionally, there is an incidence of hyperperfusion syndrome of the extremity, but a technique to address this is stated later. Incision is made in the infraclavicular fossa on the left or right side. Right side is preferred if there is any hypoxia issue as this will guarantee the best oxygen delivery to arch vessels. This also leaves the left side available for implantable defibrillator placement if the need arises. The pectoralis major is divided along the line of the incision. The pectoralis minor is reflected inferiorly to gain access to the axillary fat pad. It is here that the vein, artery, and nerves lie. The artery is usually posterior to the vein, and one can access it by reflecting the vein superiorly, although occasionally the vein is reflected inferiorly. The artery is freed up and elevated by a vessel loop. After heparinization, it is clamped distally and proximally. A longitudinal incision is made and can be extended using an aortic punch. We use a 10-mm sealed Dacron graft as the sidearm. This graft is beveled and sewn in an end-to-side fashion using 6-0 prolene on a small needle (CV-1 USS, BV-1 Ethicon). Meticulous hemostasis is critical to the success of this cannulation technique. We first remove the distal clamp to allow collateral circulation to pressurize the anastomosis. The graft is clamped with a padded vascular clamp to prevent damage to the gelatin coating. All bleeding, even needle-hole–associated bleeding, is repaired with small sutures. Small felt or pericardial pledgets can be used if required. The proximal clamp is then removed to fully pressurize the graft. Again, all bleeding must be resolved at this point. A 32-F malleable venous cannula is used to cannulate this graft to allow connection to the 3/8 in tubing. We cut the tip off the venous cannula to allow a large end hole to reduce shear stress. This cannula is tunneled into the wound in a subpectoral tunnel using a 36-F chest tube to avoid damaging it or allowing debris to enter its lumen. This is then inserted into the Dacron graft to within 2 cm of the anastomosis and tied in placed with several heavy ties. The cannula is then pulled back until the Dacron graft lies well without any kinking. The Dacron graft will lie partially in the tunnel but should not come close to the external tunneling site. Only the cannula should be exiting the skin to prevent Dacron graft infection. The cannula is then affixed to the skin with multiple sutures. If one is concerned about potential hyperperfusion syndrome of the extremity, placement of a flow restrictor on the distal axillary artery is an option. Our experience suggests that patients with relatively small axillary arteries are at higher risk for this complication so they can be used selectively. If one decides to do so, a vessel loop can be double wrapped (Potts) around the distal axillary artery and then secured with medium clips until the desired level of occlusion is achieved. One must significantly impair the lumen (80% stenosis) to create adequate flow restriction. One alternative can be to use dual radial arterial lines and constrict the artery until the mean arterial pressure is equal in both arms, once the circuit has been initiated at full flow. To allow stability of the cannulation site in the early period, an arm sling to immobilize the arm, as one would do with clavicular fracture, can be helpful. LAD = left anterior descending.