Network Meta-Analysis of Axillary, Femoral, and Central Arterial Cannulation in Minimally Invasive Cardiac Surgery

The optimal arterial cannulation site in minimally invasive cardiac surgery (MICS) remains debated. While axillary, femoral, and central approaches each offer distinct advantages, no prior network meta-analysis has compared all 3. We conducted a Bayesian network meta-analysis of 11 retrospective studies including 11,353 patients to evaluate their impact on postoperative outcomes. The analysis examined mortality, stroke, acute kidney injury (AKI), aortic dissection, atrial fibrillation, reoperation for bleeding, and length of stay, reporting odds ratios (ORs) with 95% credible intervals (CrIs) and ranking strategies using Surface under the cumulative ranking curve (SUCRA) probabilities. Central cannulation was associated with the lowest odds of stroke and aortic dissection, whereas axillary cannulation carried significantly higher odds of stroke compared with central (OR 4.66; 95% CrI 1.60 to 17.08) and ranked lowest across most outcomes. Femoral cannulation demonstrated favorable trends in in-hospital mortality (OR 0.61; 95% CrI 0.13 to 1.69 vs central) and AKI (OR 0.65; 95% CrI 0.35 to 1.19), although not statistically significant. SUCRA rankings identified central as most favorable for neurologic and vascular complications, and femoral as strongest for mortality and renal outcomes. In conclusion, central cannulation may provide the most balanced risk profile in MICS, particularly in minimizing neurologic and vascular events, while femoral cannulation remains a valid alternative in patients without significant aortic disease. Axillary cannulation, despite its theoretical benefits, was associated with higher complication rates and warrants further prospective evaluation.