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Ann Thorac Surg 1996;61:1292
© 1996 The Society of Thoracic Surgeons

Correspondence

Distal Limb Protection During Cardiopulmonary Bypass

Shuji Fukunaga, MD, Aritomo Egashira, MD, Kohichi Arinaga, MD, Shigeaki Aoyagi, MD

Second Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830 Japan

To the Editor:

In a recent issue of The Annals, Greason and colleagues [1] described a technique to prevent a distal limb ischemia during cardiopulmonary support. In their technique, an 8.5F cordis catheter was inserted into the superficial femoral artery and connected to the side port of the cardiopulmonary support arterial line. The cordis catheter was directed distally, and its flow rate was regulated at 159 ± 13 mL/min during cardiopulmonary support, considering that the resting blood flow in the superficial femoral artery of a normal leg is 150 mL/min [2]. Using this technique, they had no complications during cardiopulmonary support.

In October 1995, we applied this technique in a 67-year-old woman with repeat mitral stenosis and complete occlusion of an aortic bifurcation (Leriche's syndrome) when she underwent a heart operation under cardiopulmonary bypass. She had previously suffered a cerebral embolism with left hemiplegia in 1986 and was diagnosed with mitral stenosis, at which point open mitral commissurotomy was performed. She was admitted to our hospital in 1995 for a mitral valve operation because of another cerebral embolism, and a left atrial thrombus was detected by transesophageal echocardiogram. At admission, the electrocardiogram showed atrial fibrillation, and Leriche's syndrome was noticed for the first time, but she had no complaints of limb ischemia because the left hemiplegia limited her activity. Her ankle pressure index was 0.67 in both legs on Doppler study. To prevent limb ischemia during cardiopulmonary bypass, we prepared another pump with a bifurcated line for perfusion of the bilateral limbs in addition to the general perfusion pump. At operation, a 14-gauge intravenous catheter (Angiocath; Becton Dickinson Vascular Access Co) was directly inserted into both superficial femoral arteries with minimal preparation, as shown in Figure 1Go. In a catheter of that diameter, the maximum flow rate is 250 mL/min in each line. Bilateral limb perfusion was performed while the ascending aorta was clamped and its flow rate was regulated at 300 mL/min (150 mL/min in each limb). Mitral valve replacement and maze procedure were performed with no acidosis, no hemolysis during separate perfusion, and no complication of limb ischemia after the operation.



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  		Fig 1. . Schema of the pump with a bifurcated line for perfusion of the bilateral limbs in addition to the general perfusion pump. A 14-gauge intravenous catheter (Angiocath; Becton Dickinson Vascular Access Co) was directly inserted into both superficial femoral arteries.

 
In conclusion, this technique is useful in preventing limb ischemia not only in cardiopulmonary support but in heart operations with angiopathic complications. By separating the limb perfusion pump from the general perfusion pump, we consider that we can maintain the limb perfusion safety and effectively. The perfusion flow rate of 150 mL/min in each limb, based on the normal flow rate in the superficial artery, is optimal to prevent limb ischemia, as Greason and associates described.

References

  1. Greason KL, Hemp JR, Maxwell JM, Fetter JE, Moreno-Cabral RJ. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation. Ann Thorac Surg 1995;60:209–10.[Abstract/Free Full Text]
  2. Strandness DE, ed. Hemodynamics for surgeons. New York: Grune & Stratton, 1975:209–11.




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