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Ann Thorac Surg 1996;61:730-733
© 1996 The Society of Thoracic Surgeons

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Case Report

Thigh Ischemia Complicating Femoral Vessel Cannulation for Cardiopulmonary Bypass

Divisions of Trauma and Critical Care, and Cardiothoracic Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts

Accepted for publication July 29, 1995.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
Compartment syndrome of the lower leg is an occasional complication of prolonged ischemia and reperfusion. Compartment syndrome of the thigh is a less well-recognized complication. We present 2 patients with compartment syndrome of the ipsilateral thigh after femoral arterial and venous cannulation for cardiopulmonary bypass. Early diagnosis and urgent decompressive fasciotomy may limit the extent of local tissue damage and subsequent myonephropathic syndrome.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
Compartment syndromes of the lower leg are a well-recognized complication of ischemia/reperfusion after arterial occlusion and in the presence of extensive venous occlusion. Because collaterals are more established in the proximal thigh, thigh compartments are rarely involved with purely vascular syndromes. Compartment syndrome of the thigh is a rarely reported problem, usually associated with direct trauma to the thigh musculature with or without femur fractures [1–4]. Compartment syndrome of the thigh resulting from vascular compromise is an unusual complication [5]. We report 2 patients with thigh compartmental hypertension associated with femoral arterial and venous cannulation during cardiopulmonary bypass.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
Patient 1
Patient 1 was a 66-year-old diabetic man 10 years status post coronary artery bypass grafting who presented with recent-onset exertional angina. Coronary catheterization revealed restenosis of the previous coronary bypass grafts and severe mitral regurgitation. He underwent mitral valve repair and coronary revascularization through a retrograde left femoral arterial and venous cannulation. A 20F Sarns arterial cannula (Sarns 3M Healthcare, Ann Arbor, MI) was directed cephalad through the common femoral artery and a 27F Bio-Medicus venous cannula (Bio-Medicus, Eden Prairie, MN) was inserted in the common femoral vein. Vascular clamps were placed distally below the cannulas for hemostasis. The patient was intermittently placed on cardiopulmonary bypass and the cannulas remained in the femoral vessels for approximately 8 hours. The cannulas were removed and the arterial defect closed with a saphenous vein patch graft with minimal return of distal pulses. It was noted at the time of decannulation that the distal arterial clamp had incorporated the origin of the profunda femoris artery. Adequate arterial and venous flow were documented in the femoral vessels using the continuous wave Doppler ultrasound. The left anterior thigh and the entire left calf were tense to palpation and a four-compartment fasciotomy was performed on the lower leg and a medial incision was used to decompress the thigh. Compartment pressures were not measured. The quadriceps musculature bulged into the incision as the fascia was incised and peripheral pulses returned. The medial and posterior thigh compartments remained soft. Postoperatively, myoglobinuria developed, with the serum creatinine kinase level rising to 58,000 units responding to alkaline diuresis over the subsequent days. Creatinine levels became elevated to 2.1 mg/dL and the potassium level became transiently elevated as well, both returning to normal over subsequent days. The thigh and lower leg fasciotomy wounds were closed primarily on postoperative day 10 and he was discharged to a rehabilitation facility on day 18 with normal neurovascular function in the left leg.

Patient 2
Patient 2 was a 50-year-old hypertensive man presenting with a 1-day history of chest, abdominal, right leg, and lower back pain. Abdominal examination was unremarkable, no peripheral pulses were noted in the right leg and normal pulses were detected in the left leg. Chest roentgenogram showed a widened mediastinum. The serum creatinine kinase level was 3,500 units and the serum creatinine level was 2.8 mg/dL. Transthoracic echocardiography revealed a normal ascending aorta and aortic valve. Transesophageal echocardiography revealed a descending thoracic aortic dissection beginning at the origin of the left subclavian and extending to below the diaphragm. An acute descending thoracic aortic dissection was identified through a left posterolateral thoracotomy. The patient was heparinized after exposure in the chest was completed and the left common femoral artery and common femoral vein were cannulated with a 20F Sarns arterial cannula and a 27F Bio-Medicus venous cannula. ``Noncrushing clamps'' were placed on the distal common femoral artery and vein. Distal aortic perfusion was maintained using partial left heart femoral vein to femoral artery cardiopulmonary bypass for a total of 2 hours. The type B thoracic aortic dissection was repaired using a 28-mmAu: OK? woven double velour hemashield (Meadox Medicals, Oakland, NJ) interposition graft. The cannulas were removed after a total of 2.5 hours, the femoral artery was repaired first with monofilament suture and flow reestablished into the left leg. The femoral venous defect was primarily repaired and venous outflow established 15 minutes later. Adequate pulses were obtained in the right, previously ischemic limb; however, the entire left leg became swollen and tense with faintly audible distal pulses by continuous wave Doppler ultrasound. Reexploration of the left groin revealed audible flow in both the femoral vessels. Embolectomy catheters were passed distally with no return of clot and vigorous return of blood from the profunda and modest backflow from the superficial femoral artery. The arteriotomy was closed and the distal pulses remained faintly audible. No compartment pressures were measured. The anterior compartment of the thigh was extremely tense, the medial and posterior compartments were soft and pliable. An anterior thigh fasciotomy incision was performed with bulging of the quadriceps into the wound and four-compartment fasciotomies were carried out in the lower leg followed by restoration of palpable distal pulses. His postoperative course was marked by the myonephropathic syndrome with a peak creatine kinase level of 116,000 units, myoglobinuria, mild hyperkalemia, with a peak creatinine level of 8.8 mg/dL, all of which resolved with vigorous alkaline diuresis. He remained in the intensive care unit for 10 days and underwent primary closure of the fasciotomy wounds on postoperative day 28, eventually being discharged on postoperative day 31 with normal neurovascular function in the left leg.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

 
These 2 patients had thigh and lower leg compartment syndrome after femoral vessel cannulation for cardiopulmonary bypass are distinctly unusual. Thigh compartmental hypertension in this setting is an unusual complication.

Compartment syndrome was classically defined by Mubarak and Owens [6] as an elevation of the interstitial pressure in a confined osseofascial compartment with resultant compromise of the microcirculation. Persistent compartmental hypertension exceeds the critical closing pressure of the arterioles exacerbating muscle ischemia leading to myonecrosis. The critical threshold above which tissue ischemia results is variable for there are experimental data showing that tissue necrosis occurs at an interstitial pressure of 30 mm Hg [6]. The syndrome has been detected in the compartments of the lower leg, foot, forearm, and much less commonly in the thigh. The thigh may be at less risk than the lower leg for two reasons. First, the thigh is generously supplied by collaterals around the hip and second, the thigh musculature blends with that of the hip and therefore, may allow decompression of cellular swelling before compartmental hypertension develops.

Femoral artery injury or atherosclerotic occlusion followed by reperfusion are known to contribute to lower leg compartment syndrome [7]. Rarely has thigh compartment syndrome been described resulting from vascular injury or atherosclerosis. Schwartz and colleagues [1] described a patient suffering from a contusion to the abdominal wall resulting in the equivalent of the ``seatbelt aorta'' or aortic thrombosis. Details are scant but the patient underwent aortic reconstruction and revascularization of the lower extremities. No mention of the duration of lower extremity ischemia or adequacy of pulses was made. Postoperatively, pressures measured in the anterior and medial thigh compartments were 56 and 30 mm Hg, respectively. This patient underwent fasciotomies only to succumb to unrelenting coagulopathy and renal failure.

In addition, Williams and co-workers [5] reported a case of compartment syndrome of the lower leg resulting from cannulation of the femoral artery and vein during cardiopulmonary bypass in a child. Compartmental hypertension developed, and the child underwent four compartment lower leg fasciotomies with a residual footdrop. No thigh ischemia or edema was mentioned.

During femoral arterial and venous cannulation, direct axial blood flow to the lower leg is totally interrupted from the cannula and often a distal vascular clamp is applied to the distal common femoral artery. Blood flow to the leg continues by collaterals from the internal iliac arteries and lumbar arteries to the profunda femoris collaterals and then to the lower leg through the descending branch of the lateral femoral circumflex artery or back to the superficial femoral artery.

In our first patient, prolonged femoral artery cannulation time resulted in profound ischemia. Experimentally, microscopic myonecrosis begins after 4 hours of ischemia and becomes clinically apparent after 6 to 8 hours, although the individual variability of collateral flow makes this an arbitrary cut-off [6]. In addition, the distal arterial clamp incorporated the femoral artery bifurcation that then compromised retrograde flow back into the superficial femoral artery. This is equivalent to temporary ligation of the femoral artery bifurcation for 8 hours.

The importance of maintaining patency of the femoral artery bifurcation is well illustrated from the data concerning infected aneurysms of the common femoral artery in drug addicts. Reddy and colleagues [8] described ligation of single arteries in the groin (ie, common femoral, superficial femoral, profunda femoris without reconstruction in the presence of infected pseudoaneurysms and had no amputations). In contrast, there was a 33% incidence of extremity amputation attributable to ischemia in those patients requiring ligation of both vessels of the common femoral artery bifurcation. Simultaneous occlusion of both the superficial femoral and the profunda femoris arteries may result in profound leg ischemia while the groin cannulas are in place. The relative frequency with which this is done and the rarity with which thigh compartment syndrome develops may speak for individual variation in collateral flow to the leg. A single clamp on the common femoral artery distal to the cannula may allow continued collateral flow through the profunda to superficial femoral artery route.

We suspect that both the prolonged ischemic time and clamping of the orifice of the profunda femoris artery played a role in the first patient, although the finding that this was not apparent in the second patient indicates that additional factors were at play. Whenever there is manipulation of the femoral vessels for cannulation, there is always the risk of embolization of atherosclerotic debris into the distal vasculature resulting in end-organ dysfunction and prolonged ischemia. There was no clinical evidence for more distal emboli in the feet.

Occasionally blood escapes from the cannula site and may seep into the deep tissues of the compartment to contribute to overall swelling. However, in each of these patients there was no hematoma noted in the anterior compartment when the fasciotomy was performed. The elevation of pressure was thought to be purely on the basis of ischemia/reperfusion. Additional evidence for this as a manifestation of ischemia/reperfusion rests with the finding that the lower leg was also involved as well as the thigh in both patients and also required decompressive fasciotomies.

In both of our patients this resulted in elevated compartment pressures in the anterior compartment of the thigh with relative sparing of the medial and posterior compartments (Fig 1). The blood supply of the anterior compartment in which the quadriceps muscles reside is derived primarily from the descending branch of the lateral femoral circumflex artery and from the branches of the superficial femoral artery. In the majority of cases of thigh compartment syndrome with a mixed cause, the anterior compartment seems more at risk [1]. The fact that the bulk of the thigh musculature is found anteriorly may help to explain this predisposition. The anterior compartment in the lower leg is also more prone to develop compartment syndrome for unclear reasons [9].

View larger version (33K): [in this window] [in a new window]   Fig 1. . Cross-section of mid-thigh musculature demonstrating the three compartments of the thigh. (Reproduced with permission from J Bone Joint Surg 1989;71A:392–400.)

In addition, a synthetic graft may be sutured end-to-side to the common femoral artery and the cannula placed within the graft to maintain flow distally into the femoral vessels. This requires additional time for graft attachment and may serve as a source of suture line bleeding in the groin.

As more complicated reoperative coronary revascularizations are performed, the femoral vessels will be exposed more frequently for cannulation and the ipsilateral lower extremity will be put at risk for ischemia/reperfusion and possible compartmental hypertension. Heightened awareness of this potential will help to avoid the deleterious effects through careful cannulation of the common femoral artery, maintaining patency of the profunda femoris artery during bypass, minimizing cannulation time, maximizing perfusion pressure through collateral flow, allowing partial venous drainage and early recognition followed by timely intervention to correct the problem should it develop. Lower leg compartment syndrome has been well-described and the same vigilance must be applied to the thigh musculature. If one anticipated prolonged need for groin cannulation, preparation could be made to perfuse and establish drainage from the ipsilateral leg through the cardiopulmonary bypass circuit to avoid prolonged ischemia.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment References

 
Address reprint requests to Dr Gates, Division of Trauma and Critical Care, Brigham and Women's Hospital, Francis St, Boston, MA 02115.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Schwartz JT, Brumback RJ, Lakatos R, Poka A, Bathon GH, Burgess AR. Acute compartment syndrome of the thigh: a spectrum of injury. J Bone Joint Surg 1989;71:392–400.[Abstract/Free Full Text]
2. Viegas SF, Rimoldi R, Scarborough R. Acute compartment syndrome in the thigh: a case report and review of the literature. Clin Ortho Relat Res 1988;234:232–4.
3. Blader AH. Acute compartment syndrome of the thigh: case report. J Trauma 1990;30:1420–3.[Medline]
4. Rooser B, Bengtson S, Hagglund G. Acute compartment syndrome from anterior thigh contusion: a report of eight cases. J Orthop Trauma 1991;5:57–9.[Medline]
5. Williams PH, Bhatnagar NK, Wisheart JD. Compartment syndrome in a five-year-old child following femoral cannulation for cardiopulmonary bypass. Eur J Cardiothorac Surg 1989;3:474–5.[Abstract]
6. Mubarak SJ, Owen CA. Compartmental syndrome and its relation to the crush syndrome: a spectrum of disease. Clin Orthop 1975;113:81–9.[Medline]
7. Sanderson RA, Foley RK, Mclvor GWD, Kirkaldy-Willis WH. Histological response on skeletal muscle to ischemia. Clin Orthop 1975;113:27–35.[Medline]
8. Reddy D, Smith RF, Elliott JP Jr, Haddad GK, Wanek EA. Infected femoral artery false aneurysms in drug addicts: evolution of selective vascular reconstruction. J Vasc Surg 1986;3:718–23.[Medline]
9. Patman RD, Thompson JE. Fasciotomy in peripheral vascular surgery. A report of 164 patients. Arch Surg 1970;101: 663–70.[Abstract/Free Full Text]
10. Rahm M, Probe R. Extensive deep venous thrombosis resulting in compartment syndrome of the thigh and leg: a case report. J Bone Joint Surg 1994;76:1854–7.[Free Full Text]

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