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Ann Thorac Surg 1997;64:884-885
© 1997 The Society of Thoracic Surgeons
Boston Regional Medical Center, 3 Woodland Rd, Suite 322, Stoneham Ma 02180
To the Editor:
The technique described in the recent article by Vander Salm [1] is yet another safe and simple alternative to obtain an arterial access site for cardiopulmonary bypass (CPB) without compromising the limb antegrade blood flow [2]. This method is useful when the surgeon is occasionally faced with a difficult technical problem of femoral artery cannulation in older patients ravaged by peripheral vasculopathy, in whom the likelihood of vascular ischemia is high.
Two issues deserve mentioning because of their clinical relevance: First, although there is no disagreement that prevention of limb ischemia can be accomplished using this technique (the excellent results of Dr Vander Salm speak for themselves) it behooves us to underscore the necessity for a heightened clinical alertness and increased level of awareness for early recognition and urgent treatment of post-cardiopulmonary bypass limb compartment syndrome when it does occur. I vividly recall an otherwise unremarkable case where multiple end-organ failure ensued very rapidly, secondary to this syndrome, which was inadvertently missed within 6 hours postoperatively, rendering successful resuscitation and outcome futile. This profound, rapid, and highly abnormal triggered body response suggests to me that perhaps the ongoing cellular myonecrosis in conjunction with simultaneous endothelial injury [3] is not only a synergistic effect, but results in a systemic inflammation of a much greater magnitude that follows prolonged periods of cardiopulmonary bypass than in a classic posttraumatic injury. This hypothesis remains to be proved experimentally. At the present time, the best practical approach is to spot the compartment syndrome as early as possible based on careful, sound, and vigilant clinical judgment, as well as by sequential Doppler assessments. It is obvious that the ipsilateral limb in question must remain totally uncovered in the intensive care unit (unlike the oversight that happened in my aforementioned case) for prompt inspection and intervention on a constant basis.
Second, in an experience of more than 30 cases of brachiocephalic arteriovenous prosthetic graft insertion for vascular access in patients maintained on chronic hemodialysis, no suture hole bleeding has occurred since I have switched from using the standard polypropylene suture (Prolene; Ethicon, Somerville, NJ) to polytetrafluoroethylene suture (Gore-Tex CV6-TT9; W.L. Gore & Associates, Flagstaff, AZ). Furthermore, chronic hemodialysis causes vascular endothelial cell damage and coagulation factor disturbances not unlike cardiopulmonary bypass [4]. When polytetrafluoroethylene suture is used, the troubling needle hole bleeding has been significantly reduced by swaging the suture onto a needle of equal diameter. Additionally, the suture is "undensified" outside its needle attachment portion [5]. Thus, at the initial few passes the filament fills in the hole created as the needle goes through the graft. Consequently, a simple solution to overcome the disadvantageous suture line bleeding as reported by Dr Vander Salm is to use Gore-Tex suture of similar size instead of Prolene without the need to decrease the dose of heparin at the initial construction of the anastomosis and risk clot formation. (I have no commercial associations with the Gore-Tex product.)
References
Division of Cardiac Surgery, University of Massachusetts Medical Center, 55 Lake AveN, Rm S3-751, Worcester, Ma 01655-0304
To the Editor:
I thank Dr Alameddine for his kind comments. I agree with his recommendation for vigilant awareness of possible postoperative leg ischemia after heart operations. We, too, have seen severe complications as a consequence of belated recognition of femoral artery occlusion. My index case, however, was not one of missed diagnosis from inadequate vigilance. The compartment syndrome was recognized immediately upon removal of the surgical drapes, but because of the duration of the operation, the calf muscle necrosis was already irreversible despite prompt surgical treatment.
I have not substituted polytetrafluoroethylene sutures for polypropylene sutures to reduce suture hole bleeding from the graft. It is an excellent suggestion and one I might well adopt, although my enthusiasm for this change will be tempered by a vigilance for excess costs: 5-0 polypropylene sutures cost about $3.20, whereas CV6 polytetrafluoroethylene sutures cost about $13.50.
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