Arterial Injuries from Femoral Artery Cannulation with Port Access Cardiac Surgery

Abstract

Although minimally invasive (MI) cardiac surgery reduces blood loss, hospital stay, and recovery time, some MI approaches require femoral arterial cannulation, which introduces a heretofore unknown risk of femoral arterial injury. This study was performed to examine the risk of femoral arterial injury after Port Access MI cardiac surgery (PA-MICS) with femoral cannulation. Data were prospectively obtained on 739 consecutive patients who had PA-MICS with femoral cannulation between June 1996 and April 2000, identifying any patient with new (<30 days postoperative) arterial insufficiency from the cannulation site. Patient characteristics (gender, age, height, weight, body surface area, smoking, peripheral vascular disease, diabetes) and operative variables (cannula size, cross-clamp time) were examined with univariate and multivariate analysis to identify risk factors for arterial injury. Injuries were defined and classified by radiologic and intraoperative assessment, and follow-up was obtained by patient examination and from the medical records. Femoral arterial occlusion (FAC) occurred in 0.68% (5/739) of patients (4 women, 1 man; age range 26-74 years). The risk of femoral injury was higher in women: 1.31% vs 0.23% (p = 0.07). One patient had intraoperative limb ischemia from iliofemoral dissection and was treated by axillopopliteal bypass. Four patients presented postoperatively with claudication. Three of these had iliofemoral arterial occlusion or localized iliofemoral dissection and were treated with iliofemoral bypass, and 1 patient had localized femoral artery stenosis treated by angioplasty. With a mean follow-up of 17.8 months (range 13-26 months) limb salvage was achieved in all patients. Secondary or tertiary interventions were required in 40% (2/5), both in patients with iliofemoral occlusion, and 1 patient (20% of femoral injuries, 0.135% of overall series) has chronic graft occlusion and long-term claudication. The risk of arterial injury after femoral arterial cannulation and perfusion for Port Access surgery was low (0.68%). This risk is increased in women and is unpredictable. Initial vascular repair has a significant failure rate, and secondary interventions are often necessary. Although the femoral cannulation and perfusion technique is safe overall, the risk must be clearly recognized.

Preoperative Vascular Imaging for Predicting Intraoperative Modification of Peripheral Arterial Cannulation during Minimally Invasive Mitral Valve Surgery

“…6 They cited this risk and the risks of embolization and stroke when there is retrograde perfusion of an atheromatous thoracic aorta as the reason behind the increasing use of central cannulation in their practice. In another article on the complications of femoral cannulation, they reported a small but present risk of arterial complications with peripheral cannulation.…”

“…3 In some centers, a minimally invasive approach has become the standard for mitral valve surgery. 6,7 Notably, in addition to the risks, femoral perfusion may be rendered more difficult with the use of the intraluminal aortic occlusion balloon catheter because it occupies a significant part of the femoral cannula lumen (9F catheter in a 21F or 23F cannula). Femoral arterial cannulation, in particular, is not without risk, with potential complications including groin wound infection, wound seroma, intraoperative arterial injury requiring reconstruction, aortic dissection, atheroembolism, and limb ischemia.…”

Incidence and Treatment of Arterial Access Dissections Occurring during Cardiac Catheterization

“…However, major arterial access dissections are unlikely to have been missed, because they would likely lead to limb ischemia. Femoral cannulation for cardiopulmonary bypass during minimally invasive cardiac surgery resulted in femoral arterial injuries (likely dissections) in seven of the 739 patients (0.9%) 14 …”

Robotic mitral valve surgery

“…Vascular injuries from femoral cannulation include arterial occlusion, localized arterial injuries, and aortic dissections. Major aortic dissections are rare, but can be devastating and occur in one to two percent of operations [25][26][27][28]. Peripheral vascular disease and tortuous vasculature can be assessed preoperatively by computed tomography.…”