Complications of Femoral Cannulation
Femoral cannulation is commonly used to obtain central access during cardiac bypass using various versions of the Seldinger technique. Caparas, Hu and Hung (2014), in a comparison study of the modified Seldinger technique (MST) and the accelerated Seldinger technique (AST), found the AST was both faster, resulted in less blood loss, decreased air-to- vessel exposure incidence, and decreased infection in their small sample. These differences were statistically significant. Tsiouris, Elkinany, Ziganshin, and Elefteriades (2016) analyzed the use an open Seldinger guided femoral cannulation procedure on 303 patients. The survival rate overall was 97% (98% for elective surgeries). However, femoral cannulation can cause significant complications.
According to Malviyal, Yadav, Negi and Singh (2011), complications resulting from femoral vein cannulation include hemorrhage, phlebitis, thrombosis, fistulas, pseudo-aneurysms and damage to the femoral nerve. Saadat et al. (2017) compared 72 cardiac surgeries from September 2012 to September 2013 where femoral cannulation (FC) was used to 274 surgeries which used aortoarterial cannulation (AC). The incidence of stroke in FC was 1.39% compared to 2.19% when A/C was used. Incidence of atrial fibrillation for FC was 13.9% and for AC was 16.5%; renal failure was 2.78% versus 4%, hemorrhage with need for an additional operation was 4.17% versus 4.74%. These differences were not statistically significant; however, because of the findings the authors postulated femoral cannulation has no significant differences in complication and mortality rates than aortoarterial cannulation.
Tsiouris et al. (2016) noted risk of stroke is a concern since FC can mobilize plaque and debris from arterial walls leading to emboli in the brain; but, this has not been universally reported as a complication (Fusco, Shaw, Tranquilli, Kopf, & Elefteriades, 2004; Kouchoukos, Masetti, Rokkas & Murphy, 2002; Lakew, Pasek, Zacher, Diegeler & Urbanski, 2005; Okita et al., 1998). In Tsiouris et al.’s study of 303 FC patients using the open Seldinger technique, there were zero instances of malperfusion, ischemia, dissection or vascular injury. Wound complications were present in 1% of patients and the stroke incidence was 1%.
Bangalore (n.d.) notes to prevent complications, a detailed patient history is crucial. In patients with a weak or absent femoral pulse, iliofemoral bypass grafts, prior vascular complications, prior groin surgery with scarring, morbid obesity, or the inability to lie flat for extended periods are all contra-indications that may result in procedural complication. In addition, Bangalore and Bhatt (2011) note the groin and leg area should be inspected for incidence of an active infection. Regarding complications, Bangalor (n.d.) states the incidence of an arteriovenous fistula after femoral cannulation is less than 0.1% and the incidence of pseudoaneurysm is between 1-3% of patients undergoing this procedure. He indicates dissection of the femoral artery can occur which may cause acute limb ischemia in less than 1% of patients. He also notes retroperitoneal hemorrhage; a serious complication occurs in less than 2% of patients.
Both patients and physicians must be cognizant of the complications that can arise from femoral cannulation though overall incidence rates are small. An analysis must be made to ensure there are no contraindications and the benefits of the procedure will outweigh the cost of complication and mortality for the patient.
References
Bangalore, S. & Bhatt, D.L. (2011, August 2). Femoral arterial access and closure. Circulation, 124, e147-e156. https://doi.org/10.1161/CIRCULATIONAHA.111.032235
Bangalore, S. (n.d.) Femoral arterial access and its complications. Journal of Family Practice. Retrieved from https://www.mdedge.com/jfponline/dsm/9019/cardiology/femoral-arterial-access-and-complications
Caparas, J., Hu, J.P. &Hung, H.S. (2014) Does a novel method of PICC insertion improve safety? Nursing,44(5) 65-7. https://doi.org/10.1097/01.NURSE.0000444725.83265.1d.
Fusco, D.S., Shaw, R.K, Tranquilli M., Kopf, G.S. & Elefteriades, J.A. (2004). Femoral cannulation is safe for type A dissection repair. Annals of Thoracic Surgery,74,1285–9.
Kouchoukos, N.T., Masetti, P, Rokkas, C.K. & Murphy, S.F. (2002). Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Annals of Thoracic Surgery,74 (9), 1885-1887(Suppl).
Lakew F., Pasek, P., Zacher, M., Diegeler, A. & Urbanski, .P.P. (2005). Femoral versus aortic cannulation for surgery of chronic ascending aortic aneurysm. Annals of Thoracic Surgery, 80, 84-88.
Malviyal, A., Yadav, J.K., Negi, N. & Singh, C.G. ( 2013, February). Learning from mistakes: Femoral vein cannulation-an unusual complication or blessing in disguise. Indian Journal of Surgery, 75(1), 79-81. https://doi.org/10.1007/s12262-011-0323-5
Okita, Y., Takamoto, S., Ando, M., Morota, T., Matsukawa, R. & Kawashima, Y. (1998). Surgery for acquired heart disease. Journal of Thoracic Cardiovascular Surgery,115(8)129–138.
Saadat, S., Schulheis, M., Azzolini, A., Romero, J., Dombrovskiy, V.,…Lee, L. (2016). Perfusion, 31(2), 131-134. https://doi.org/10.1177/0267659115588631
Tsiouris, A., Elkinany, S., Ziganshin, B.A. & Elefteriades, J.A. (2016, July). Open Seldinger femoral artery cannulation technique for thoracic aortic surgery. The Annals of Thoracic Surgery, 101(6)2231-2235. http://dx.doi.org/10.1016/j.athoracsur.2015.12.032
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