Supra-inguinal Femoral Artery Cannulation In Robotic Cardiac Surgery: Size (and Where You Cannulate) Matters!
Hiroto Kitahara, Blaine Johnson, Yuki Ikeno, Sara Nisivaco, Kaitlin Grady, Husam Balkhy.
The University of Chicago, Chicago, IL, USA.
BACKGROUND: Femoral artery cannulation can be challenging in patients with peripheral vascular disease or small femoral vessels especially when endo-aortic balloon occlusion is used because of the larger size cannula requirement. We have utilized a supra-inguinal femoral cannulation technique which can provide for a larger size femoral artery and maintain distal perfusion by preserving collateral arteries. The details of our technique and strategy are evaluated. METHODS: We reviewed the arterial cannula size in the last 133 consecutive patients who underwent robotic surgery for intracardiac pathology at our institution over a 16-month period. Aorto-iliofemoral CT angiography is obtained in all patients preoperatively and the cannulation site, size and arrest technique are chosen based on an optimal perfusion strategy algorithm (Figure). Our first choice is to use endo-aortic balloon occlusion which requires either a size 21 or 23Fr cannula. In patients not suitable for the endo-aortic balloon a regular size18, 20 or 22Fr cannula is used with a transthoracic clamp or ventricular fibrillatory arrest. Supra-inguinal femoral cannulation is performed with direct cut down above the level of the inguinal ligament. The femoral artery is dissected and cannulated above the level where multiple collaterals arise including the superficial and deep circumflex iliac arteries laterally; and the inferior and superficial epigastric arteries as well as the superficial and deep external pudendal arteries medially. RESULTS: During the study period, 133 patients underwent robotic cardiac surgery including 105 mitral valve, 11 aortic valve, 7 isolated MAZE procedure and others. Five patients required axillary cannulation and are excluded from this analysis. The mean body surface area is 1.95+- 0.26 m2. The mean maximum and minimum diameters of the supra-inguinal femoral artery were 9.7+/-1.6 mm and 8.7+/-1.6 mm respectively. 73% of patients had a 21Fr or larger cannula and the majority (54%) were 23Fr with the endoballoon. No leg ischemia or femoral artery dissection requiring additional intervention have occurred. CONCLUSIONS: Supra-inguinal arterial femoral cannulation allowed for the utilization of a relatively larger cannula size for a variety of perfusion strategies in robotic cardiac surgical procedures without any leg or vascular complications. LEGEND: Perfusion strategy in robotic cardiac surgery 
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