Axillary vs. Femoral Cannulation in Minimally Invasive Valve Surgery: Outcomes from a Matched and Unmatched Cohort Analysis

All articles of this category (opens in new window) Background: The optimal cannulation strategy in minimally invasive valve surgery remains debated. Femoral cannulation with retrograde perfusion is considered contraindicated in aortoiliac disease. Since 2021, we have used axillary cannulation in these cases. We compared outcomes of axillary vs. femoral cannulation. Methods: From 2019 to 2023, 604 patients underwent minimally invasive valve surgery via mini-thoracotomy with axillary ( n = 66) or femoral ( n = 538) cannulation. Baseline and outcome data were analyzed, and case-control matching was performed for age, EuroSCORE II, BMI, and peripheral vascular disease, yielding 61 matched pairs. Results: In the unmatched cohort, axillary patients were older (68.1 vs. 61.5 years, p < 0.01), with more COPD (10.6% vs. 3.7%, p = 0.01), chronic renal failure (10.6% vs. 5.6%, p = 0.01), and prior cardiac surgery (15.2% vs. 3.5%, p < 0.01). Cross-clamp times were shorter (79 vs. 103 minutes, p < 0.01), and extubation in the operating room was more frequent (69.7% vs. 61.9%, p = 0.02). Postoperatively, delirium (18.2% vs. 8.9%, p < 0.01), hemiplegia (4.5% vs. 1.1%, p = 0.04), and myocardial infarction (1.5% vs. 0.4%, p = 0.04) occurred more often in axillary patients, while 30-day mortality did not differ (3.0% vs. 1.3%, p = 0.52). After matching, neurological outcomes were comparable (composite endpoint 26.2% vs. 16.0%, p = 0.27), whereas renal injury (9.8% vs. 1.6%, p = 0.05) and dialysis (6.5% vs. 0%, p = 0.04) occurred more often after femoral cannulation. Conclusion: Axillary cannulation was mainly applied in older and higher-risk patients. While crude analysis suggested more neurological complications, matched analysis demonstrated comparable neurological outcomes and a lower incidence of renal injury. Axillary cannulation represents a safe alternative to femoral access and may provide renal protection in high-risk patients. A randomized trial is underway to further investigate optimal cannulation strategies. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany