Femoral Cannulation for CPB During Minimally Invasive Cardiac Surgery

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This video demonstrates the technique of open cut down femoral vessel cannulation for cardiopulmonary bypass (CPB) during minimally invasive cardiac surgery procedures. The case involved a 36-year-old male patient with severe aortic regurgitation and preserved left ventricular ejection fraction. The operation was performed via an anterior thoracotomy in the second intercostal space, using the semi-Seldinger technique to establish cardiopulmonary bypass.

Patient Selection

Femoral vessel cannulation is contraindicated in patients with certain conditions. These include occlusion or stenosis of the femoral and iliac arteries, where the residual patent lumen is smaller than the diameter of the aortic femoral cannula, and aneurysm, dissection, or thrombosis of the abdominal or descending thoracic aorta.

Operative Steps

The procedure began with preoperative planning using contrast-enhanced CT imaging and 3D CT reconstruction to determine the optimal cannulation site. A skin incision was then made behind the femoral vessels, no longer than 3 cm. Complete dissection of the anterior vascular surface from the fascia was performed, followed by the placement of longitudinal purse-string sutures using 5/0 polypropylene with a 13 mm needle. The vessel was punctured with a standard 16G Venflon catheter, and guidewire insertion was conducted under transesophageal echocardiography (TEE) guidance. After dilator passage, the anterior vascular wall was incised with a scalpel, allowing for the cannula to be introduced into the vessel lumen without resistance. The arterial cannula was securely fixed, and the purse-string sutures were reinforced during decannulation, always for the artery and as needed for the vein.

Routine Tools

The routine tools included a standard 16G Venflon catheter, a hydrophilic-coated guidewire made of silicone or stainless steel, and an arterial cannula, either the EOPA 18-20 Fr or the Fem-Flex II 16 Fr. The venous cannula options were the Bio-Medicus multistage femoral venous cannula 25 Fr or the Bio-Medicus One-Piece femoral venous cannula 21 Fr. 

Tips for Success

Contrast-enhanced CT imaging was used preoperatively to plan the incision and cannulation site while identifying vascular lesions that could contraindicate cannulation. The authors ensured that purse-string sutures were in a longitudinal configuration to prevent vessel stenosis after tightening. Intraoperative TEE guidance was utilized for precise positioning of guidewires and venous cannula. The anterior vascular wall incision was made with a scalpel to ensure smooth and resistance-free cannula passage. The authors also reinforced arterial purse-string sutures to enhance security.

References

1. Babliak O, Demianenko V, Marchenko A, Babliak D, Melnyk Y, Stohov O, et al. Left anterior minithoracotomy as a first-choice approach for isolated coronary artery bypass grafting and selective combined procedures. European Journal of Cardio-Thoracic Surgery. 2023 May 5; Available from: http://dx.doi.org/10.1093/ejcts/ezad182

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