Alternative Arterial Access in Veno-Arterial ECMO: The Role of the Axillary Artery

Abstract

Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used to support patients with refractory cardiogenic shock or cardiac arrest. While femoral artery cannulation remains the most common arterial access, axillary artery cannulation has emerged as a valuable alternative in selected cases. Objective: This narrative review aims to synthesize current evidence and expert opinion on axillary artery cannulation in V-A ECMO, focusing on its technical feasibility, physiologic implications, and clinical outcomes. Methods: A comprehensive literature search was performed in PubMed and Scopus using relevant keywords related to ECMO, axillary artery, cannulation techniques, and outcomes. Emphasis was placed on prospective and retrospective clinical studies, expert consensus statements, and technical reports published over the past two decades. Results: Axillary cannulation provides antegrade aortic flow, potentially reducing the risk of differential hypoxia and improving upper body perfusion. However, the technique presents unique technical challenges and may carry risks such as hyperperfusion syndrome or arterial complications. Emerging data suggest favorable outcomes in selected patient populations when performed in experienced centers. Conclusions: Axillary cannulation represents a promising arterial access route in V-A ECMO, particularly in cases with contraindications to femoral cannulation or when upper-body perfusion is a concern. Further prospective studies are needed to better define patient selection criteria and long-term outcomes.

Keywords: ECMO cannulation; axillary ECMO; axillary artery cannulation; cannulation strategy; extracorporeal life support; femoro-axillary ECMO; femoro-axillary configuration; veno-arterial ECMO.

Figure 1

The axillary artery is divided into three segments relative to the pectoralis minor; arterial cannulation for V-A ECMO is usually performed on the third segment. Caution is required to avoid injury to nearby structures such as the brachial plexus, subclavian vein, and posterior circumflex humeral artery. 1: first segment of axillary artery; 2: second segment of axillary artery; 3: third segment of axillary artery. Figure author-generated.

Figure 2

(A) Delto-pectoral incision following the natural groove between the deltoid (laterally) and the pectoralis major (medially), extending from the coracoid process toward the axillary fold. (B) Infraclavicular incision performed 1–2 cm inferior to the clavicle, parallel to its long axis, enabling exposure of the axillary artery beneath the clavicular head of the pectoralis major. (C) Surgical axillary cannulation with an 8 mm Dacron graft anastomosed end to side to the axillary artery. (D) Arterial cannula tunneled subcutaneously and connected to a Dacron graft anastomosed to the axillary artery. Created in BioRender 201.

Figure 3

Sonographic assessment of the axillary artery. (A) Linear probe positioned transversely, perpendicular to the axis of the upper limb. (B) Linear probe positioned longitudinally, parallel to the axis of the upper limb. (C) Out-of-plane view of the axillary artery and axillary vein. (D) In-plane view of the axillary artery. AA: Axillary artery; AV: Axillary vein. Figure Author generated using BioRender 201.

Figure 4

Stepwise illustration of percutaneous axillary artery cannulation. (A) Ultrasound-guided arterial puncture. (B) Insertion of the guidewire using the Seldinger technique. (C) Syringe withdrawal, with the Seldinger guidewire left in place within the arterial lumen. (D) Sequential dilation of the access tract over the guidewire. (E) Advancement and positioning of the arterial ECMO cannula. (F) Withdrawal of the Seldinger guidewire. Created in BioRender 201.

Figure 5

Comparison of arterial flow patterns in femoro-femoral (F-F) versus femoro-axillary (FAx) ECMO. In femoro-femoral (FF) ECMO, arterial flow is retrograde toward the aortic arch, increasing the risk of differential hypoxia. In femoro-axillary (F-Ax) ECMO, flow is anterograde, favoring cerebral and coronary perfusion. ECMO F-F: femoro-femoral ECMO; ECMO F-Ax: femoro-axillary ECMO. Created in BioRender 201.

Figure 6

Proposed algorithm for axillary cannulation in adult requiring V-A ECMO. BMI: body mass index; PAD: peripheral artery disease; TASC: Trans-Atlantic Intersociety Consensus; NSS: North–South syndrome; LVEF: left ventricular ejection fraction; pO₂: partial pressure of oxygen; US: ultrasonography; CABG: coronary artery bypass grafting; IMA: internal mammary artery. Created in BioRender 201.