Single, Percutaneous, Femoral Venous Cannulation for Cardiopulmonary Bypass

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Slide 1 : Single, Percutaneous, Femoral Venous Cannulation forCardiopulmonary Bypass William Riley, LP, CCP Brigham and Women’s Hospital Boston, MA
Slide 2 : Venous Cannulation The perfusionist’s role in venous cannula choice is critical Superior or inferior vena caval location Bicaval, atrial, or peripheral insertion One – three stage design 18f – 51f sizes
Slide 3 : Peripheral Venous Cannulation Kinetic and vacuum assisted venous return accommodate single peripheral venous cannulation Peripheral venous cannulation is commonly associated with minimally invasive and re-operative procedures
Slide 4 : Caseload Considerations….BWH
Slide 5 : Caseload Considerations….BWH
Slide 6 : Circuit Cobe Smarxt tubing Apex oxygenator HVR 4000i reservoir 1 liter prime Vacuum assisted venous drainage (<100mmhg max net vacuum) allows single, percutaneous, femoral venous cannulation
Slide 7 : Who? Any patient whose surgical procedure would be facilitated by peripheral venous cannulation (minimally invasive, reoperative, thoracotomy, etc.) Body surface area (BSA) >2.0 may require additional cannulae, but peripheral cannulation still plays important role
Slide 8 : What? Edwards Lifesciences Research Medical Fem-Flex II 20fr femoral venous cannula Sizes available 18fr - 31fr To be used in conjunction with a percutaneous insertion kit for dilatation and wire guidance
Slide 9 : When? Insertion may take place anytime after patient prep is complete Full heparinization prior to cannula insertion Prior to sternotomy for re-operations Thoracotomy patients are often cannulated supine, prior to positioning
Slide 10 : Where? Right or left common femoral vein (65% Right, 35% Left) Advanced along inferior vena cava (IVC) via iliac vein Cannula tip should be located from junction of IVC/right atrium to SVC, dependent on the procedure Cannula may be advanced or retracted from insertion site n = 788
Slide 11 : Why? Attainable venous return is adequate for much of the patient population
Slide 12 : Why? (cont.) In our experience, percutaneous insertion is associated with lower infection rate and faster healing time than cut down approach Small external cannula diameter ensures appropriate drainage of abdominal organs, which may be impeded by larger diameter femoral venous cannulae Additional cannulae may be used if necessary
Slide 13 : How? Cannulation is usually performed by physician assistant or cardiac surgical resident Percutaneous insertion is preferred over cut-down (65% single femoral venous cannula cases were percutaneous) Femflex insertions performed as cut down were usually in conjunction with ipsilateral, open femoral arterial cannulation
Slide 14 : Guidewire Insertion Common femoral vein 1-2cm below inguinal ligament Insert .035 inch Amplatz extra-stiff guidewire using Seldinger technique With echo guidance, Advance guidewire to desired cannula tip location (RA/IVC)
Slide 15 : Advancement of Cannula Femoral vein dilated Cannula with obturator advanced over guidewire “U” stitch for stability and closure Any adjustments while on CPB may be confirmed with echo
Slide 16 : Connection to Circuit 3/8 x 3/8 x 1/2 inch connector 6 foot x 3/8 inch tubing, double clamped, available for SVC cannulation if necessary (28% of all femoral venous cases utilized a second cannula) Cannula attached via small length of 3/8 inch tubing
Slide 17 : Requirements Adequate systemic flow Venous saturation Acid/Base status Blood pressure Avoidance of cerebral malperfusion MAP - CVP = MCP Increases in cerebral blood flow require greater SVC drainage
Slide 18 : Requirements (cont.) Decompression of heart Reduction of myocardial oxygen demand by limiting collateral blood flow and maintaining relaxed myocardium Safer sternotomy for reoperative and aortic procedures
Slide 19 : Removal Femflex must be removed prior to reversal of heparin Once cannula is removed, “U” stitch is cinched, usually no compression is necessary DVT incidence is not elevated

 


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