Risk Factors Of Limb Ischemia In Minimally Invasive Cardiac Surgery From The Viewpoint Of Anatomy Of Femoral Artery
Takayuki Kawashima, Sr., Tomoyuki Wada, Takashi Shuto, Keitaro Okamoto, Madoka Kawano, Kyohei Hatori, Kazuki Mori, Takeshi Wada, Hirofumi Anai, Shinji Miyamoto.
Oita University, Yufu-shi, Oita, Japan.
Background: In minimally invasive cardiac surgery (MICS),the common femoral artery (CFA) cannulation during cardiopulmonary bypass (CPB) could cause limb ischemia (LI). We hypotheses that lack or poor collateral circulation via the deep femoral artery (DFA) or side branches may be more significant than the size discrepancy in terms of LI. This study evaluates the risk factors of LI in MICS from the point of view of anatomy of the femoral arteries. Methods: We performed a retrospective review of 47 patients who were underwent MICS without prosthetic graft conduit for femoral arterial cannulation between January 2014 and August 2017 at our institution. Regional oxygen saturation (rSO2) of both lower extremities was monitored during the operation by INVOS®︎. The diameters of CFA, surperficial femoral artery (SFA) and DFA were measured using preoperative computed tomography. Based on those diameters and the presence or absence of side branches that can be collateral circulation, we divided them into the following 4 anatomical types (type A: DFA > SFA without branch, type B: DFA < SFA with side branch in CFA, type C: DFA < SFA with side branch in bifurcation of SFA and DFA, type D: DFA < SFA without side branch). We used maximum value of postoperative creatine kinase (CKmax) as the index of postoperative LI. To exclude the influence of each muscle mass, CK divided the area of muscles of femoral regions and it is defined as CK/MA. The predictor for LI, including age, sex, body surface area (BSA), body mass index (BMI), CPB time, the diameter of CFA, SFA and DFA, remaining lumen size of CFA after the cannulation, the anatomical types of femoral artery and the baseline and the drop rate from the baseline of rSO2 of lower extremities were analyzed. Results: No critical limb ischemia occurred in 47 patients. In the anatomical type of femoral artery, type A was the most numerous (type A: 27 (57%) legs, type B: 5 (11%) legs, type C: 3 (6%) legs, type D: 12 (26%) legs). In this cohort, the median CKmax was 1973 U/L (1293-2894) and the median CK/MA was 15.6 U/L/cm2 (9.9 -20.1). In multivariate analysis of CK/MA > 20, anatomical type D was only predictor(Odds ratio 7.188; 95% confidence interval: 1.023- 50.506, p= 0.0047) and the remaining lumen size of CFA after the cannulation and the drop rate of rSO2 were not predictor. Conclusions: Our result suggested anatomical type D was risk factor for LI in MICS.In type D cases, attention should be paid to the choice of the cannulation site.
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