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Ann Thorac Surg 1996;61:1291-1292
© 1996 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, Glenfield Hospital, Groby Rd, Leicester LE3 9QP, United Kingdom
To the Editor:
We read with interest the report by Greason and associates [1] concerning the prevention of distal limb ischemia during extracorporeal life support. Although this is a devastating complication if it occurs, we believe that the avoidance of distal ischemia does not require any special equipment or technical skill over and above that normally required for extracorporeal life support. In our series of 199 patients on extracorporeal life support [2], 39 adults were supported with 60% survival, venovenous cannulation being used in 82% of cases.
Venovenous access can be used for almost all cases of respiratory failure, even in the presence of pulmonary hypertension, as oxygenated blood is a powerful pulmonary vasodilator. The percutaneous placement of large (28F) cannulas via the femoral and jugular veins has not resulted in venous congestion in any of our patients. Thus only a small proportion of patients will actually need venoarterial support: of 7 such adult patients in our series, 2 had open chest cannulation for failure to be weaned from cardiopulmonary bypass. In the other 5 patients cannulated via extrathoracic arteries there were no episodes of distal ischemia. This is achieved either by cannulating an artery with good collateral supply, which can therefore be ligated (brachial or carotid), or by cannulating the artery without ligation, thereby allowing antegrade flow around the cannula. We have done this successfully in the carotid and femoral arteries. The cannula may be inserted through a pursestring, or by using a ``semi-Seldinger'' technique where the artery is exposed, then a guidewire is inserted, followed by the dilators and cannula.
The safety of placing a distal femoral perfusion cannula percutaneously after extracorporeal life support has been established and the patient is heparinized must be questioned. We believe that this procedure is very likely to result in life-threatening hemorrhage into the thigh. Surgical cannulation as described above, with the use of electrocautery and fibrin glue [3], does not result in severe hemorrhage in our experience.
References
General Surgery and Clinical Investigation Departments, Naval Medical Center, San Diego, CA 92134-5000
To the Editor:
We believe that Peek and associates misunderstood the main point of our article. It was not meant to promote the use of arteriovenous cardiopulmonary support over its venovenous counterpart for respiratory failure. The focus of our article was to highlight the possible complication of femoral artery occlusion during arteriovenous cardiopulmonary support, a complication reported in 2% of 569 cases [1]. We believe this low rate of complication makes prophylactic distal limb perfusion unnecessary. However, if arterial occlusion occurs, it must be dealt with in an efficient and effective manner.
We describe a rapidly applied, safe, and simple method to achieve distal perfusion. As stated in our article, we used the modified Seldinger technique: exposure of the femoral artery surgically and puncture of its anterior wall under direct vision. We agree that unsuccessful attempts to cannulate the femoral artery percutaneously can cause serious bleeding, especially in the fully heparinized patient.
Peek and associates report on the effective use of percutaneous femoral cannulas without the occurrence of venous hypertension. Their experience is also supported by that of Teirstein and colleagues [2] and Vogel and co-workers [2]. We discuss venous hypertension in our article only as a possible concern after restoration of arterial blood flow to an ischemic extremity and provide a reasonable method of correcting the hypertension should it occur.
Acknowledgments
The Chief, Navy Bureau of Medicine and Surgery, Washington, DC, Clinical Investigation Program sponsored this report 84-16-1968-563, as required by HSETCINST 6000.41A. 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 US Government.
References
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