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Ann Thorac Surg 1995;60:209-210
© 1995 The Society of Thoracic Surgeons

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How To Do It

Prevention of Distal Limb Ischemia During Cardiopulmonary Support via Femoral Cannulation

Departments of General Surgery (Cardio-Thoracic Surgery Division) and Clinical Investigation, Naval Medical Center, San Diego, California

Accepted for publication March 28, 1995.

	Abstract

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

 
The indications for prolonged cardiopulmonary support or extracorporeal membrane oxygenation are expanding. A potential serious complication of these techniques is distal limb ischemia. Techniques have been developed to provide the distal limb with blood flow. Unfortunately, specialized skills and materials are required. We describe a simple method of providing distal limb perfusion using ordinary pressure tubing and a standard cordis catheter. This technique is capable of reproducing normal superficial femoral artery blood flow.

	Introduction

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

 
Cardiopulmonary support (CPS) or extracorporeal membrane oxygenation through the femoral vessels is becoming more frequent. Its use has been expanded to emergency resuscitation after cardiac arrest in the catheterization laboratory or intensive care unit [1]. Emergency bypass systems are being applied to support patients with hypothermia, reversible pulmonary disease, or low output states who benefit from bypass alone allowing time to correct underlying metabolic and physiologic problems [2]. As a bridge to cardiac transplantation, CPS has supported patients for up to 6 days [3]. During CPS or extracorporeal membrane oxygenation, the intravascular catheter often completely occludes the arterial lumen. Therefore, a potentially serious complication of prolonged cannulation is distal limb ischemia [4]. Currently described techniques for distal limb perfusion require use of bidirectional arterial cannulas or special right-angle, high-flow arterial cannulas [5]. These techniques require specialized skill and less readily available equipment. They cannot be used in a percutaneous manner. We describe a method for establishing distal limb perfusion using equipment readily available in the hospital setting. Our technique can be instituted rapidly and with minimal preparation.

	Technique

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

 
After CPS is established, a standard 8.5F Arrow-Flex cordis catheter (Arrow International, Inc, Reading, PA) is placed into the superficial femoral artery. The cordis catheter's point of insertion is distal to that of the CPS arterial line. This can be accomplished via the percutaneous Seldinger technique or via direct cannulation if the artery already has been exposed for placement of the CPS catheter. The cordis catheter is directed distally into the superficial femoral artery and connected to the side port of the CPS arterial line (Fig 1). This can be accomplished without modification of the CPS arterial cannula. The connection is best made with tubing approved for use with arterial pressure wave monitoring. This arrangement allows for CPS via the large-bore arterial line and perfusion of the limb distally via the cordis catheter.

View larger version (21K): [in this window] [in a new window]   Fig 1. . Cardiopulmonary support arterial catheter entering the common femoral artery with the side branch providing flow into the cordis catheter down the superficial femoral artery.

	Results

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

 
This technique has been used clinically in 2 patients. The first patient required CPS for refractory pulmonary hypertension after pneumonectomy. In the second patient, low cardiac output developed in the post–coronary artery bypass period. Distal limb perfusion was established in both patients via the modified Seldinger technique as described above. Specifics of each patient's CPS run are shown in Table 1. Neither patient experienced complication related to distal limb perfusion.

	Comment

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

Another area of concern is the potential for venous hypertension. If femoral venous outflow obstruction exits (ie, secondary to the CPS venous cannula), then as arterial inflow is established, acute venous hypertension may develop. Acute venous hypertension associated with CPS use was not reported in Teirstein and associates' review of 569 cases [4]. This is confirmed by our own experience; furthermore, the restoration of arterial blood flow to the extremity has failed to result in clinical evidence of acute venous hypertension. If venous outflow obstruction is of major concern, an option is to use the internal jugular vein for venous cannulation rather than the common femoral vein.

Resting blood flow in the superficial femoral artery of a normal leg is approximately 150 mL/min, with popliteal artery flow of about 100 mL/min [6]. Using the perfusion technique described in this report, we demonstrated that normal superficial femoral artery flow rates through the cordis catheter can be achieved. Although some baseline vascular resistance of the distal limb is expected, this should be minimal due to ischemia-induced vasodilatation of the vascular bed [7]. This rapidly applied, safe, and simple technique achieves the goal of adequate distal limb perfusion during femorally applied CPS or extracorporeal membrane oxygenation.

	Acknowledgments

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

 
The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program sponsored this report #84-16-1968-507, as required by HSETCINST 6000.41A.

	Footnotes

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

 
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Address reprint requests to Dr Greason, Clinical Investigation Department, Naval Medical Center, San Diego, CA 92134-5000.

	References

Top Footnotes Abstract Introduction Technique Results Comment Acknowledgments References

 

1. Phillips SJ, Zeff RH, Kongtahworn C, et al. Percutaneous cardiopulmonary bypass: application and indication for use. Ann Thorac Surg 1989;47:121–3.[Abstract]
2. Hill JG, Bruhn PS, Sheldon CE, et al. Emergent applications of cardiopulmonary support: a multiinstitutional experience. Ann Thorac Surg 1992;54:699–704.[Abstract]
3. Moreno-Cabral CE, Moreno-Cabral RJ, McNamara JJ, Dembitsky WP, Adamson RM. Prolonged extracorporeal circulation for acute myocarditis. Int J Artif Organs 1991;14:565.
4. Teirstein PS, Vogel RA, Dorros G, et al. Prophylactic versus standby cardiopulmonary support for high risk percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1993;21:590–6.[Abstract]
5. Read R, St. Cyr J, Tornabene S, Whitman G. Improved cannulation method for extracorporeal membrane oxygenation. Ann Thorac Surg 1990;50:670–1.[Abstract]
6. Strandness DE, ed. Hemodynamics for surgeons. New York: Grune & Stratton, 1975:209–11.
7. Sumner DS. Essential hemodynamic principles. In: Rutherford RB, ed. Vascular surgery. 4th ed. Philadelphia: Saunders, 1995:18–44.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kevin L. Greason James R. Hemp John E. Fetter Ricardo J. Moreno-Cabral Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Greason, K. L. Articles by Moreno-Cabral, R. J. Search for Related Content PubMed PubMed Citation Articles by Greason, K. L. Articles by Moreno-Cabral, R. J.