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Ann Thorac Surg 1998;65:1194-1195
© 1998 The Society of Thoracic Surgeons
a Department of Surgery, University of Oulu, Kajaanintie 52 A, FIN-90220 Oulu, Finland
To the Editor
We read with interest the recent article by Dr Vander Salm [1] in which he presented a novel method for preventing lower extremity ischemia during cardiopulmonary bypass via femoral cannulation. To ensure distal leg perfusion he used a 10-mm polytetrafluoroethylene graft sewn end-to-side to an arteriotomy in 19 patients over a 15-month period with good results. The decision to choose polytetrafluoroethylene as a graft was based on its good resistance to infection. One possible disadvantage mentioned by Dr Vander Salm was suture line bleeding through the needle holes during full heparinization.
The turning point in our practice of femoral cannulation was in 1986, when prolonged perfusion via the femoral artery led to lower limb ischemia, femoral amputation, and finally the death of the patient. We had previously seen some minor complications of low distal leg perfusion leading to compartment syndromes, which had been managed by means of fasciotomies. On account of these experiences, we have been routinely using over a 10-year period a method analogous to that reported by Dr Vander Salm except that our graft option was coated 10-mm Dacron. So far we have used this method in 54 patients with no ischemic or infectious complications. One inguinal lymphocele was managed by revision.
Because bleeding through the needle holes may cause a serious problem during the full heparinization required for cardiopulmonary bypass, one possible advantage of a coated Dacron graft, in our opinion, is that there is no bleeding problem of the kind encountered with polytetrafluoroethylene material. On the other hand, one possible limitation of the use of this otherwise feasible method could be emergency cannulation, because sewing the graft is more time-consuming. Our option for coping with this is to draw the graft onto the cannula as a bolster, perform temporary direct cannulation to start the perfusion, and suture the graft to the side of the femoral artery when the situation permits and then slide the cannula from inside the artery onto the graft to allow bidirectional flow at the femoral level.
We entirely agree with Dr Vander Salm that this easily applied technique offers an opportunity to avoid distal leg ischemia during cardiopulmonary bypass via femoral cannulation. Our 10-year experience shows that a coated Dacron graft is safe and may offer an opportunity to avoid harmful needle hole bleeding during cardiopulmonary bypass. The bolster method described here means that this technique is also applicable in emergency cases.
References
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