Peripheral cannulation is a major step for establishing
of cardiopulmonary bypass in minimally invasive
cardiac surgery and in certain open chest procedures.
Traditionally, a transverse arteriotomy incision or a
purse suture over the arterial wall can be used during
open cannulation of the femoral artery. Herein, we
present an alternative technique for femoral artery
cannulation with the Seldinger method, which uses
double-pledgeted horizontal sutures on the anterior
wall of the femoral artery.
SURGICAL TECHNIQUE
After marking the course of the femoral artery in
the groin, an oblique 3 cm incision was made 1 cm
above the inguinal crease. The subcutaneous tissue
and femoral sheath were opened using a scissor.
Dissection was made laterally to the femoral vessels
to avoid lymphatic injury and lymphorrhea. Only
anterior surfaces of the femoral artery and vein were
dissected and exposed (Figure 1). The fascia and
surrounding tissue around the vessels were kept
intact. Systemic heparinization was made, before
the suture placement and cannulation. A double
pledgeted U-suture of 5/0 polytetrafluoroethylene
was, then, placed at the anterior side of the common
femoral artery (Figure 2). Bites were superficially
taken through the adventitial layer of the femoral
artery. There should be two pledgeted U-sutures
on the anterior surface of the femoral artery. The distance between each suture line should be 1 mm,
and the length of each bite should be 3 mm long
horizontally. If the anterior wall was calcified, the sutures were placed more laterally or medially in a
suitable plaque-free area. Femoral access was, then,
performed using the Seldinger technique in the
midpoint between the two pledgeted sutures. After
the dilatation of the artery with a 15-F or 17-F dilatator over the 0.035-inch guidewire, the arterial
cannula was inserted. An oval shaped, double
purse-string suture (5/0 polypropylene) was placed at
the anterior side of the common femoral vein. Each
suture should be 1 mm away from each other. Using
the Seldinger technique, the vein was punctured
inferiorly to the oval-shaped purse suture (Figure 3).
The puncture site was dilated using a 15-F or 17-F
dilatator over the 0.035-inch guidewire. Before the
insertion of the venous cannula, the anterior wall
of the femoral vein, lying in the oval purse suture,
was incised 2 mm superiorly (Figures 2 and 3). The
venous cannula was, then, immediately inserted
through the vein with gentle maneuvers. All these
steps of peripheral cannulation were performed under
the guidance of transesophageal echocardiography
(Figure 4). At the end of the procedure, the arterial
cannula was removed, and the cannulation site
was washed out in an antegrade and retrograde
fashion. All two pledgeted sutures were, then,
ligated (Figure 5). Sutures on the vein were also
tied, before the delivery of the protamine following
cardiopulmonary bypass.
Figure 1: Surgical exposure of
common femoral artery and vein
(upper image), placement of doublepledgeted
polytetrafluoroethylene
sutures on the femoral artery and
prolene sutures on the common
femoral vein (lower image).
Figure 2: Placement of the sutures. Double-pledgeted sutures
are horizontally placed through the adventitial layer of the
femoral artery (FA) (top image). Red dot shows the puncture
site in the middle of two-layered horizontal sutures. Note
the distances of sutures. Double purse suture on the anterior
surface of the common femoral vein (FV) (bottom image).
Red dot shows the puncture site and dotted white line shows
the 3 mm incision horizontal and superior incision before
insertion of venous cannula.
Figure 3: Double-pledgeted sutures on the femoral artery
and a 3 mm incision over the femoral vein before insertion of
the venous cannula.
Figure 4: An intraoperative transesophageal echocardiography guidance view during peripheral
cannulation. In the left lower view, guidewire (arrow) is shown in the descending aorta (DA). In
the right lower view, guidewire is seen in the right atrium (RA).
Figure 5: Femoral artery and vein after tying sutures.
A postoperative computed tomography
angiography image revealed a natural course of the
femoral artery with a gentle curve (Figure 6). The diameters of the proximal and distal segment of the
common femoral artery in the cannulation site were
similar without a stenosis or occlusion.
Figure 6: A computed tomographic image following
peripheral cannulation of the femoral vessels.
In conclusion, in patients undergoing minimally
invasive cardiac surgery, particularly with mini-incisions
such as port-access operations or robotic approach,
peripheral cannulation is of paramount importance for
establishing cardiopulmonary bypass. Our experience
shows that this technique is simple, safe, and feasible
for peripheral cannulation. Over the past five years,
this technique has been routinely used in more than
300 minimally invasive and robotic procedures, as well
as redo surgeries in our hospital. No procedure-related
morbidity including leg ischemia perioperatively, or a
vascular morbidity such stenosis, thrombosis, dissection
or occlusion has been reported during follow-up to date.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.