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Ann Thorac Surg 1997;63:251-252
© 1997 The Society of Thoracic Surgeons

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How To Do It

Prevention of Lower Extremity Ischemia During Cardiopulmonary Bypass via Femoral Cannulation

University of Massachusetts Medical Center, Worcester, Massachusetts

Accepted for publication July 30, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Results Comment References

 
Prolonged cardiopulmonary bypass requiring femoral arterial cannulation may lead to ipsilateral leg ischemia. A technique described of femoral cannulation via an end-to-side femoral artery graft allows distal femoral perfusion and eliminates the complication of leg ischemia.

	Introduction

Top Footnotes Abstract Introduction Technique Results Comment References

 
Cardiopulmonary bypass for aortic reconstruction often requires femoral arterial cannulation. Standard femoral cannulation results in occlusion of the femoral artery around the cannula, thus eliminating antegrade flow into the distal femoral artery and possibly resulting in lower extremity ischemia [1]. Even the cannulation for percutaneous (femoral artery to femoral vein) bypass with smaller and presumably nonoccluding catheters over a short period of time leads to an 11% incidence of femoral complications with a 2% incidence of femoral occlusion [2].

I encountered the need for prolonged femoral cannulation during an emergency, redo replacement of the aortic arch, ascending aorta, aortic valve, coronary arteries, and atrial septum requiring nearly 11 hours of cardiopulmonary bypass. The resulting leg ischemia from the femoral arterial cannulation led to an above-knee amputation. Because of this complication, my technique of femoral cannulation has been changed to one that prevents leg ischemia during femoral cannulation. Other techniques to avoid or subsequently treat this complication have been described [3–5]. The technique described here, however, seems to be simpler, is universally applicable, and causes no reduction in the available femoral artery lumen.

	Technique

Top Footnotes Abstract Introduction Technique Results Comment References

 
Expose the common femoral artery as for standard femoral cannulation. After systemic heparinization, occlude the artery both proximally and distally. Suture to a longitudinal arteriotomy a segment of a 10-mm standard polytetrafluoroethylene (PTFE) graft in an end-to-side fashion with a 5-0 polypropylene suture (Fig 1). Release the femoral arterial occlusion, and place a clamp on the graft. After bleeding has been controlled, cannulate the graft with a 24F femoral cannula (Fig 2). The bulb on the cannula should fit snugly in the graft. Loop an umbilical tape around the cannula and graft above and below the cannula bulb and tie securely. Connect the cannula to the standard arterial inflow tubing from the arterial pump head. During the operation, blood will flow without obstruction both proximally (and hence to the remainder of the body) and distally in the femoral artery.

View larger version (29K): [in this window] [in a new window]   Fig 1. . Suture a 10-mm polytetrafluoroethylene (PTFE) graft end-to-side to an arteriotomy in the common femoral artery.

View larger version (38K): [in this window] [in a new window]   Fig 2. . Cannulate the graft with a 24F femoral cannula. Secure the cannula in the graft by tying around the graft with umbilical tape above and below the bulb on the cannula.

View larger version (30K): [in this window] [in a new window]   Fig 3. . After discontinuation of cardiopulmonary bypass, staple across the graft, leaving a 1-cm cuff. Amputate the remaining graft.

	Results

Top Footnotes Abstract Introduction Technique Results Comment References

	Comment

Top Footnotes Abstract Introduction Technique Results Comment References

 
Acute femoral occlusion may cause leg ischemia and lead to muscle necrosis and a compartment syndrome. This occurs most commonly with atherosclerotic disease and superimposed clot formation, but it can occur with normal vessels if the cannula is occlusive and collateral circulation is poor. It has also been reported with femoral cannulation for cardiopulmonary bypass [1, 2]. My index case required an ipsilateral above-knee amputation after femoral arterial cannulation during a long, emergency operation. Perfusion of the femoral artery via a graft sewn end-to-side onto the artery provides bidirectional flow, and thus eliminates distal ischemia. This was suggested (but not employed) by Gates and colleagues [1] in a recent description of 2 patients with thigh ischemia after cardiac operations performed with femoral arterial perfusion. Cannulation by the technique described above apportions arterial perfusion by the relative resistance of the perfused vascular beds. Thus, excessive blood flow into the perfused leg (or inadequate flow into the remainder of the body) should be prevented by autoregulation.

Although cannula insertion with this technique first requires sewing a graft onto the femoral artery, and thus takes longer to initiate cardiopulmonary bypass, that time is retrieved at the end of the case by the elimination of the need to suture an arteriotomy, and instead, simply stapling across the graft. Possible disadvantages of this technique include bleeding from the suture line during the operation, and infection at the stump of the graft left on the femoral artery. I have seen no infection, but if it is of concern in a particular patient, the arteriotomy can be closed with a saphenous vein patch. Suture line bleeding, however, has occurred through the needle holes in the PTFE graft during cardiopulmonary bypass. This may be eliminated by giving a smaller dose of heparin (5,000 U) during the construction of the anastomosis, and deferring the larger dose required for cardiopulmonary bypass until shortly before its initiation. It could also be reduced by using a collagen-impregnated, knitted Dacron graft but I continue to use the PTFE graft because of greater resistance to infection.

This easily applied technique allows femoral cannulation during cardiopulmonary bypass but eliminates the complication of distal femoral ischemia in operations requiring prolonged cardiopulmonary bypass.

	Footnotes

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Address reprint requests to Dr Vander Salm, Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655-0304.

	References

Top Footnotes Abstract Introduction Technique Results Comment References

 

1. Gates JD, Bichell DP, Rizzo RJ, Couper GS, Donaldson MC. Thigh ischemia complicating femoral vessel cannulation for cardiopulmonary bypass. Ann Thorac Surg 1996;61:730–3.[Abstract/Free Full Text]
2. 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]
3. Read R, St Cyr J, Tornabene S, Whitman G. Improved cannulation method for extracorporeal membrane oxygenation. Ann Thorac Surg 1990;50:670–1.[Abstract]
4. 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]
5. Beyersdorf F, Mitrev Z, Ihnken K, et al. Controlled limb reperusion in patients having cardiac operations. J Thorac Cardiovasc Surg 1996;111:873–81.[Abstract/Free Full Text]

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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): Thomas J. Vander Salm Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vander Salm, T. J. Search for Related Content PubMed PubMed Citation Articles by Vander Salm, T. J.