Introduction
Acute femoral artery occlusion due to remote access bypass (femoral arterial cannulation),
is a routine for pediatric minimal invasive cardiac surgery and prevention of leg
ischemia is necessary. This technique requires peripheral vessel cross clamping, which
may lead to transient perfusion deficit of the lower extremities.Strategies to prevent
muscle necrosis or development of compartment syndrome include invasive or non-invasive
monitoring of tissue oxygen saturation of involved extremity. A variety of means are
utilized, to assess lower extremity (LE) perfusion – including pulse palpation, pulse
oximetry, subjective assessment of LE by colour, temperature etc. Regional oxygen
saturation measured by near-infrared spectroscopy (NIRS), used as a potential surrogate
of cerebral and somatic mixed venous oxygen saturation-is a noninvasive tool to continuously
monitor LE perfusion. We sought to evaluate the safety of peripheral arterial cannulation
by using NIRS in such subset of patients.
Methods
We evaluated 50 pediatric patients, weight 10-30kg, age 3-12years, divided in: Group
A (N=25), - underwent peripheral femoral artery cannulation for remote access perfusion
for MICS, group B (N=25), receive conventional sternotomy incision. All patients were
monitored by transcutaneous NIRS (placed on calves of both legs) for quality control
of distal leg perfusion during cardiopulmonary bypass. Baseline NIRS value, followed
by continuous NIRS values were recorded. Total creatinine kinase (CK) and serum myoglobin
levels, mid-thigh and mid -calf circumference (to rule out compartment syndrome),
were measured at preoperatively, 6hour and 24hour after surgery. Intra-operatively,
all hemodynamic parameters along with blood gas parameters like PH, PO2, PCO2, SCVO2,
lactate etc. were recorded at baseline, on bypass, clamp on, clamp off and off bypass
period. Total CPB time, ventilation duration, hospital and ICU stay were also recorded.
Results
The baseline NIRS comparable in group A (72.6±6.86) over cannulated versus (71.76±4.05),
contralateral leg, while, in group B, it was (69.96±5.75 vs.69.84±5.50). During clamping
of femoral artery in Group A, NIRS dropped to 39.12±5.60 (vs. baseline), while it
remained stable in the contralateral leg and group B patients. After successful implantation
of the distal leg perfusion, the NIRS normalized to baseline within 5 to 7 minutes.
Myoglobin and CK levels increased in both the groups, more so in Group A. There were
no clinical side effects from increased CK or myoglobin. None of our patients had
residual vascular complications. ±±±±
Discussion
We speculate that remote CPB with direct femoral artery cannulation can be safely
used in pediatric patients- with a body weight 10-30 kg and CPB time less than 60
minutes- without increasing operative morbidity and complications. When prolonged
CPB time is expected probably one should change the MICS policy by adding selective
distal leg perfusion to minimize the complications
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© 2021 Published by Elsevier Inc.
