Distal Leg Protection for Peripheral Cannulation in Minimally Invasive and Totally Endoscopic Cardiac Surgery

  • Nikolaos Bonaros
  • Dominik Wiedemann
  • Johann Nagiller
  • Gudrun Feuchtner
  • Christian Kolbitsch
  • Marc Kaufmann
  • Johannes Bonatti
  • Thomas Schachner


Background: The introduction of minimally invasive and totally endoscopic cardiac surgery is associated with increased use of femoral artery perfusion. Selective antegrade perfusion of the cannulated artery may be a helpful strategy to avoid ischemia of the lower extremities. The aim of the study was to evaluate the efficacy of selective distal vessel perfusion under continuous monitoring of oxygen saturation using near-infrared spectroscopy (NIRS).

Methods: All patients (n = 236) who underwent peripheral cannulation for remote access perfusion and endoaortic balloon occlusion for minimally invasive or totally endoscopic cardiac surgery were prospectively analyzed. Perioperative complications, creatine kinase levels, and major complications at the long-term follow-up were recorded.

Results: Minor or major complications of leg perfusion occurred in only 4 patients (1.7%); the complications in 2 of the patients were associated with an additional arterial cannula placed at the contralateral side. NIRS monitoring revealed diminished perfusion in 5 cases. Even patients with complications associated with remote-access perfusion had a rapid recovery, and no residual peripheral vascular complication was detected during follow-up.

Conclusions: The use of antegrade selective perfusion of the lower extremity at the side of peripheral cannulation for port-access perfusion and endoaortic occlusion is of utmost importance in patients undergoing minimally invasive or endoscopic cardiac surgery. NIRS monitoring has proved to be very helpful for the diagnosis of impaired leg perfusion.


Allen RC, Schneider J, Longenecker L, Kosinski AS, Smith RB 3rd, Lumsden AB 1993. Acute lower extremity ischemia after cardiac surgery. Am J Surg 166:124-9.\nBonaros N, Schachner T, Oehlinger A, et al. 2006. Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves and clinical outcome. Ann Thorac Surg 82:687-94.\nBonatti J, Schachner T, Bernecker O, et al. 2004. Robotic totally endoscopic coronary artery bypass. Program development and learning curve issues. J Thorac Cardiovasc Surg 127:504-10.\nBonatti J, Schachner T, Bonaros N, et al. 2006. Technical challenges in totally endoscopic robotic coronary artery bypass grafting. J Thorac Cardiovasc Surg 131:146-53.\nCasselman FP, Van Slycke S, Wellens F, et al. 2003. Mitral valve surgery can now routinely be performed endoscopically. Circulation 108(suppl 1):II48-54.\nDogan S, Graubitz K, Aybek T, et al. 2002. How safe is the port access technique in minimally invasive coronary artery bypass grafting? Ann Thorac Surg 74:1537-43.\nGlower DD, Clements FM, Debruijn NP, et al. 1999. Comparison of direct aortic and femoral cannulation for port-access cardiac operations. Ann Thorac Surg 68:1529-31.\nHendrickson SC, Glower DD 1998. A method for perfusion of the leg during cardiopulmonary bypass via femoral cannulation. Ann Thorac Surg 65:1807-8.\nJeanmart H, Casselman FP, De Grieck Y, et al. 2007. Avoiding vascular complications during minimally invasive, totally endoscopic intracardiac surgery. J Thorac Cardiovasc Surg 133:1066-70.\nLeMaire SA, Ochoa LN, Conklin LD, et al. 2006. Transcutaneous near infrared spectroscopy for detection of regional spinal ischemia during intercostal artery ligation: preliminary experimental results. J Thorac Cardiovasc Surg 132:1150-5.\nMohr FW, Falk V, Diegeler A, et al. 2001. Computer-enhanced "robotic" cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 121:842-53.\nMuhs BE, Galloway AC, Lombino M, et al. 2005. Arterial injuries from femoral artery cannulation with port access cardiac surgery. Vasc Endovascular Surg 39:153-8.\nRedlin M, Boettcher W, Huebler M, et al. 2006. Detection of lower torso ischemia by near-infrared spectroscopy during cardiopulmonary bypass in a 6.8-kg infant with complex aortic anatomy. Ann Thorac Surg 82:323-5.\nReichenspurner H, Gulielmos V, Wunderlich J, et al. 1998. Port-access coronary artery bypass grafting with the use of cardiopulmonary bypass and cardioplegic arrest. Ann Thorac Surg 65:413-9.\nSagbas E, Caynak B, Duran C, et al. 2007. Mid-term results of peripheric cannulation after port-access surgery. Interact Cardiovasc Thorac Surg 6:744-7.\nSchachner T, Bonaros N, Bonatti J, Kolbitsch C 2008. Near infrared spectroscopy for controlling the quality of distal leg perfusion in remote access cardiopulmonary bypass. Eur J Cardiothorac Surg 34:1253-4.\nSchachner T, Bonaros N, Feuchtner G, Müller L, Laufer G, Bonatti J 2005. How to handle remote access perfusion for endoscopic cardiac surgery. Heart Surg Forum 8:E232-5.\nUbbink DT, Koopman B 2006. Near-infrared spectroscopy in the routine diagnostic work-up of patients with leg ischaemia. Eur J Vasc Endovasc Surg 31:394-400.\nWimmer-Greinecker G, Matheis G, Dogan S, et al. 1999. Patient selection for port-access multivessel revascularization. Eur J Cardiothorac Surg 16(suppl 2):S43-7.\n

Most read articles by the same author(s)

1 2 3 4 > >>