HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) 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): Steven C. Hendrickson Donald D. Glower Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hendrickson, S. C. Articles by Glower, D. D. Search for Related Content PubMed PubMed Citation Articles by Hendrickson, S. C. Articles by Glower, D. D.

Ann Thorac Surg 1998;65:1807-1808
© 1998 The Society of Thoracic Surgeons

---

How to Do It

A Method for Perfusion of the Leg During Cardiopulmonary Bypass via Femoral Cannulation

^a Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA

Accepted for publication February 23, 1998.

Address reprint requests to Dr Glower, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710
e-mail: (glowe001{at}mc.duke.edu)

	Abstract

Top Abstract Introduction Technique Results Comment Addendum References

 
Minimally invasive approaches for cardiac operations currently are gaining increasing attention. Some of these approaches require cannulation of the femoral vessels for cardiopulmonary bypass. A potential complication of femoral cannulation is ischemic injury to the lower extremity in some cases that require long bypass times. To minimize this risk we have begun cannulating the common femoral artery distally, as well as proximally. This technique perfuses the leg for the duration of cardiopulmonary bypass, and it can be accomplished with minimal increases in cost and operative time.

	Introduction

Top Abstract Introduction Technique Results Comment Addendum References

 
For many years median sternotomy with cannulation of the ascending aorta and right atrium/vena cava for cardiopulmonary bypass has been the standard approach for most cardiac surgical procedures. Recently, minimally invasive approaches, avoiding median sternotomy, have been introduced for a variety of cardiac operations [1]. Many of these approaches require femoral arterial or venous cannulation for extracorporeal perfusion. There is potential for ischemic injuries to the cannulated leg in these cases [2]. We have begun cannulating the femoral artery proximally and distally to provide perfusion to the lower extremity throughout the procedure.

	Technique

Top Abstract Introduction Technique Results Comment Addendum References

 
While the surgeon opens the chest via an anterior or lateral thoracotomy, the assistant exposes the femoral vessels. A transverse skin incision is made directly over the femoral vessels inferior to the inguinal ligament. The femoral sheath is opened. Proximal and distal control are obtained on the common femoral artery and vein using no. 4 braided silks with Rummell tourniquets. The only modification required to the perfusion setup is insertion of a x x -inch Y connector (Sorin Biomedical, Inc, Irvine, CA) into the arterial line on the operating table.

Venous cannulation is performed first. The common femoral vein is clamped proximally and distally, and two circumferential 5-0 polypropylene pursestring sutures are placed. A venotomy is made within the pursestring, the venous cannula (DLP, Inc, Grand Rapids, MI) is inserted, and the proximal and distal clamps are removed. The cannula is advanced to the junction of the superior vena cava and right atrium over a flexible J wire with use of transesophageal echocardiography for guidance. Once properly positioned, the venous cannula is secured and arterial cannulation is performed.

The common femoral artery is clamped proximally and distally. A transverse arteriotomy is made, leaving the posterior one third of the artery intact. A 21F or 23F arterial cannula (Heartport, Redwood City, CA) is inserted proximally over a J wire and secured with a Rummell tourniquet. The distal artery is then cannulated via the same arteriotomy with a pediatric arterial cannula (DLP, Inc). This cannula ranges in size from 8F to 14F depending on the size of the extremity and the femoral artery. Both arterial lines are then attached to the Y-connector in the arterial perfusion line (Fig 1). Deairing is accomplished by backbleeding from the distal cannula and allowing air to escape via the Endoclamp side port of the Heartport arterial cannula. Cardiopulmonary bypass then is initiated in standard fashion with assisted venous drainage. After weaning from bypass the venous cannula is removed and the pursestring suture is tied. The arterial cannulas are removed sequentially, and the transverse arteriotomy is closed using interrupted 5-0 polypropylene everting sutures.

View larger version (53K): [in this window] [in a new window]   Fig 1. The femoral vein is cannulated proximally through a pursestring suture. The common femoral artery is cannulated proximally and distally via the same transverse arteriotomy. The posterior one third of the artery is left intact. (A = Heartport arterial cannula; B = pediatric arterial cannula; C = venous cannula.)

	Results

Top Abstract Introduction Technique Results Comment Addendum References

Since we began using distal cannulation there have been no ischemic complications or paresthesias in 13 cases. There have been no local complications at the arteriotomy site secondary to dual cannulation.

	Comment

Top Abstract Introduction Technique Results Comment Addendum References

 
Minimally invasive approaches are being used with increasing frequency for cardiac surgical procedures. Some of these approaches require femoral vessel cannulation for cardiopulmonary bypass. In general, minimally invasive procedures can be performed with bypass and clamp times that are not significantly longer than those during conventional techniques. However, as with conventional approaches, the possibility exists that a prolonged bypass period may occur. This is particularly true for complex cases. Longer bypass times, which may be necessary for valve repair and multivessel coronary artery bypass grafting procedures, have the potential to cause ischemic complications in the cannulated extremity. After a case in which fasciotomies were required to avoid a compartment syndrome, we adopted a policy of changing the cannulas to the opposite groin if the bypass time exceeded 3 hours or if the patient had to be placed back on cardiopulmonary bypass for modification of a repair. Unfortunately, this approach requires an additional incision, significantly increases operative time, and subjects the patient to the risk of complications of cannulation a second time. For these reasons we now have modified our method of femoral cannulation to include distal perfusion of the femoral artery via an 8F to 14F pediatric arterial cannula. This eliminates the need to change the cannulation site in the middle of a case. We believe another potential advantage to this approach is that it may minimize release of lactic acid and other ischemic metabolites that may occur when flow is reinstituted to an extremity subjected to prolonged ischemia.

Other reported techniques for perfusing the leg include sewing a 10-mm polytetrafluoroethylene graft to the common femoral artery, then cannulating the graft rather than the artery [3]. The cost of the pediatric arterial cannula, approximately $65/cannula, is considerably lower than the cost of a polytetrafluoroethylene graft. In addition, the modification to the perfusion apparatus is minimal, the procedure takes only a few minutes to accomplish, and no prosthetic graft material is left in the groin. Greason and associates [4] reported using an 8.5F Cordis catheter (Arrow International, Inc, Reading, PA) placed percutaneously into the superficial femoral artery to perfuse the distal limb during cardiopulmonary support. However, the reinforced cannula has better flow characteristics, it can be placed via the same arteriotomy as the proximal cannula, and its flexibility allows it to be positioned without kinking.

We have primarily used this system for Port-Access–type minimally invasive cardiac procedures. However, it can be applied in any situation where femoral cannulation is used for cardiopulmonary bypass, for example some redo procedures or thoracic aneurysm operations. We now use this technique routinely. However, it could be used selectively if so desired. We have not had any local complications at the arteriotomy site secondary to this cannulation technique. The small diameter and flexibility of the pediatric cannula allow it to easily pass into the distal portion of the arteriotomy without undue trauma to the arteriotomy site.

	Addendum

Top Abstract Introduction Technique Results Comment Addendum References

 
At the time of publication, the described technique has been used in 51 patients with no evidence of limb ischemia, as opposed to 3 cases of limb ischemia in 40 cases without perfusion of the distal extremity (p < 0.05). We have further modified the technique to placing two concentric pursestrings of 5-0 Prolene (Ethicon, Somerville, NJ) suture in the femoral vein, then using snares on these 5-0 Prolene sutures and not occluding the femoral vein. Preserving venous return from the leg in this fashion has decreased the incidence of transient mild edema of the perfused distal extremity from 13/33 to 2/18 (p = 0.03).

	References

Top Abstract Introduction Technique Results Comment Addendum References

 

1. Glower DD, Landolfo KP, Clements F, et al. Mitral valve operation via Port-Access versus median sternotomy. Eur J Cardiothorac Surg (in press).
2. Gates J.D., Bichell D.P., Rizzo R.J., Couper G.S., Donaldson M.C. Thigh ischemia complicating femoral venous cannulation for cardiopulmonary bypass. Ann Thorac Surg 1996;61:730-733.[Abstract/Free Full Text]
3. Vander Salm T.J. Prevention of lower extremity ischemia during cardiopulmonary bypass via femoral cannulation. Ann Thorac Surg 1997;63:251-252.[Abstract/Free Full Text]
4. Greason K.L., Hemp J.R., Maxwell J.M., Fetter J.E., Moreno-Cabral R.J. Prevention of distal leg ischemia during cardiopulmonary support via femoral cannulation. Ann Thorac Surg 1995;60:209-210.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. W. Hammon Extracorporeal Circulation: Perfusion System Card. Surg. Adult, January 1, 2008; 3(2008): 350 - 370. [Full Text]

				E. Sagbas, B. Caynak, C. Duran, O. Sen, B. Kabakci, I. Sanisoglu, and B. Akpinar Mid-term results of peripheric cannulation after port-access surgery Interactive CardioVascular and Thoracic Surgery, December 1, 2007; 6(6): 744 - 747. [Abstract] [Full Text] [PDF]

				J. A. Magovern, J. D. Fonger, D. H.J. Wang, D. Kopilec, D. R. Trumble, and D. E. Smith A femoral artery cannula that allows distal blood flow J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 684 - 686. [Abstract] [Full Text] [PDF]

				B. E. Muhs, A. C. Galloway, M. Lombino, M. Silberstein, E. A. Grossi, S. B. Colvin, P. Lamparello, G. Jacobowitz, M. A. Adelman, C. Rockman, et al. Arterial Injuries from Femoral Artery Cannulation with Port Access Cardiac Surgery Vascular and Endovascular Surgery, March 1, 2005; 39(2): 153 - 158. [Abstract] [PDF]

				R. Sharony, E. A. Grossi, P. C. Saunders, C. F. Schwartz, G. H. Ribakove, A. T. Culliford, P. Ursomanno, F. G. Baumann, A. C. Galloway, and S. B. Colvin Minimally Invasive Aortic Valve Surgery in the Elderly: A Case-Control Study Circulation, September 9, 2003; 108(90101): II-43 - 47. [Abstract] [Full Text] [PDF]

				E. A. Hessel II and L. H. Edmunds Jr. Extracorporeal Circulation: Perfusion Systems Card. Surg. Adult, January 1, 2003; 2(2003): 317 - 338. [Full Text]

				V Kasirajan, I Simmons, J King, M D Shumaker, A DeAnda, and R S Higgins Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation Perfusion, December 1, 2002; 17(6): 427 - 428. [Abstract] [PDF]

				D. D. Glower, J. Komtebedde, F. M. Clements, N. P. Debruijn, M. Stafford-Smith, and M. F. Newman Direct aortic cannulation for port-access mitral or coronary artery bypass grafting Ann. Thorac. Surg., November 1, 1999; 68(5): 1878 - 1880. [Abstract] [Full Text] [PDF]

				D. D. Glower, F. M. Clements, N. P. Debruijn, M. Stafford-Smith, R. D. Davis, K. P. Landolfo, and P. K. Smith Comparison of direct aortic and femoral cannulation for port-access cardiac operations Ann. Thorac. Surg., October 1, 1999; 68(4): 1529 - 1531. [Abstract] [Full Text] [PDF]

				M. Ceviz, A. Ozyazicioglu, and H. Kocak The prevention of leg ischemia in femoral cannulation Ann. Thorac. Surg., April 1, 1999; 67(4): 1217 - 1217. [Full Text] [PDF]

This Article Abstract Full Text (PDF) 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): Steven C. Hendrickson Donald D. Glower Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hendrickson, S. C. Articles by Glower, D. D. Search for Related Content PubMed PubMed Citation Articles by Hendrickson, S. C. Articles by Glower, D. D.