Eur J Cardiothorac Surg 2008;34:1253-1254. doi:10.1016/j.ejcts.2008.08.027
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Near infrared spectroscopy for controlling the quality of distal leg perfusion in remote access cardiopulmonary bypass
Thomas Schachner*,
Nikolaos Bonaros,
Johannes Bonatti,
Christian Kolbitsch
Innsbruck Medical University, Innsbruck, Austria
Received 13 March 2008;
received in revised form 15 August 2008;
accepted 22 August 2008.
* Corresponding author. Address: Department of Cardiac Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. Tel.: +43 512 504; fax: +43 512 504 22528. (Email: Thomas.Schachner{at}i-med.ac.at).
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Abstract
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The prevention of leg ischemia is necessary in all patients undergoing femoral artery cannulation for extracorporeal circulation. Near infrared spectroscopy (NIRS) is an established non-invasive method for measuring tissue oxygen saturation. Ten patients underwent robotically assisted endoscopic coronary surgery or ASD repair on the arrested heart using aortic endo-occlusion catheters. They were monitored by transcutaneous NIRS (placed on both lower legs) for quality control of distal leg perfusion during femoral access cardiopulmonary bypass. The baseline NIRS values were 61 (52–80) on the cannulated side versus 70 (53–80) on the contralateral leg (p
= n.s.). During clamping of the femoral artery for installation of the remote access perfusion system the tissue oxygen saturation dropped to 38 (18–58) (p
= 0.001 vs baseline) while it remained stable on the contralateral leg. After successful implantation of the distal leg perfusion the NIRS values normalized to similar amounts on both legs. We conclude that transcutaneous NIRS of the lower legs might be a useful non-invasive tool for monitoring leg perfusion in patients undergoing extracorporeal circulation via the femoral vessels.
Key Words: Near infrared spectroscopy • NIRS • Endoscopic • Robotic • Cardiac surgery
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1. Background
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Remote access cardiopulmonary bypass (CPB) with balloon carrying catheters for aortic endo-occlusion involves transient perfusion deficits of the cannulated femoral artery. Distal femoral perfusion might be necessary to prevent prolonged leg ischemia, which carries the risk of compartment syndrome [1–3]. We aimed to test near infrared spectroscopy (NIRS) in endoscopic cardiac surgical procedures for detecting early ischemia of the lower leg following femoral cannulation. Furthermore the efficacy of distal femoral perfusion was evaluated by this non-invasive tissue oxygen saturation monitoring.
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2. Methods and results
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In 10 patients (8 male, 2 female, aged 59 (45–71) years) who underwent remote access perfusion (Heartport in 9, ESTECH in 1 patient) bilateral NIRS monitoring was placed on the medial parts of the lower leg. The operations were totally endoscopic CABG in nine and totally endoscopic ASD repair in one patient using the da Vinci telemanipulator. The cardiopulmonary bypass time was 167 (86–309) min; aortic endo-occlusion time was 108 (50–145) min.
After exposure of the femoral vessels and cannulation of the femoral vein a 5 F arterial access sheath was placed for distal leg perfusion (Fig. 1
). The arterial perfusion cannula was inserted after cross-clamping the femoral artery using a small arteriotomy. During cardiopulmonary bypass the cannulated femoral artery was perfused distally to the clamped site [1]. The NIRS values, given as median (range), of the right and left leg were recorded as baseline, as nadir after clamping of the femoral artery, and as plateau level during cardiopulmonary bypass. The statistical analysis was performed using the Mann–Whitney test. A p value <0.05 was regarded as statistically significant.
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Fig. 1. Remote access perfusion via femoral access. The femoral artery and vein are cannulated for cardiopulmonary bypass. In addition an arterial access sheath is placed in the femoral artery for distal leg perfusion.
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The baseline NIRS values were 61 (52–80) on the cannulated side versus 70 (53–80) on the contralateral leg (p
= n.s.). During clamping of the femoral artery for installation of the remote access perfusion system the NIRS values dropped to 38 (18–58) (p
= 0.001 vs baseline) while it remained stable on the contralateral leg (Fig. 2
). After successful installation of the distal leg perfusion the NIRS values rose to values of 71 (58–74) on the perfused side and 68 (53–74) on the contralateral side.
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Fig. 2. Values of near infrared-spectroscopy (NIRS) measurements on the legs of the perfused side (baseline 1, clamping 1, HLM 1) and contralateral side (baseline 2, clamping 2, HLM 2). Baseline values before femoral cannulation were compared to values after clamping of the femoral artery and values on the heart lung machine (HLM) with distal femoral perfusion on the cannulated side.
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3. Discussion
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Totally endoscopic coronary surgery and ASD repair have been implemented as routine procedures at our department of cardiac surgery [2,3]. Remote access cardiopulmonary bypass with balloon carrying devices for aortic endo-occlusion are prerequisites for endoscopic cardiac surgery on the arrested heart [1]. Since the femoral artery is completely occluded during CPB there is a risk of ischemia-reperfusion injury of the leg, which can lead to a compartment syndrome. Thus we implemented distal femoral perfusion in all our patients. Nevertheless there existed no monitoring device for acute leg ischemia. Near infrared spectroscopy measures tissue oxygen saturation transcutaneously and it is routinely used for cerebral monitoring in cardiovascular surgery [4,5]. LeMaire and co-workers showed that NIRS detected spinal ischemia during intercostal artery ligation in pigs [6]. Redlin et al. detected lower torso ischemia by NIRS in a child with complex aortic pathology undergoing cardiac surgery [7]. In another study of patients with peripheral vascular disease an exercise induced leg ischemia could be visualized with NIRS devices placed on the calves [8]. In agreement we could demonstrate in our series that transcutaneous NIRS monitoring could be implemented in totally endoscopic cardiac surgery. Furthermore we found an immediate drop of the tissue oxygen saturation with NIRS following femoral occlusion with a consecutive rise to normal values after onset of distal femoral perfusion. Thus we could validate the quality of distal leg perfusion by NIRS monitoring of the lower legs.
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4. Conclusion
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We conclude that transcutaneous measurement of tissue oxygen saturation with near infrared spectroscopy immediately shows leg ischemia after femoral artery cannulation with restoring of normal values if sufficient distal leg perfusion is provided. Thus NIRS might be useful for non-invasive monitoring of femoral blood flow in patients undergoing cannulation of the femoral artery for extracorporeal circulation.
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References
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- Schachner T, Bonaros N, Feuchtner G, Muller L, Laufer G, Bonatti J. How to handle remote access perfusion for endoscopic cardiac surgery. Heart Surg Forum 2005;8:E232-E235.[CrossRef][Medline]
- Bonatti J, Schachner T, Bonaros N, Ohlinger A, Danzmayr M, Jonetzko P, Friedrich G, Kolbitsch C, Mair P, Laufer G. Technical challenges in totally endoscopic robotic coronary artery bypass grafting. J Thorac Cardiovasc Surg 2006;131(1):146-153.[Abstract/Free Full Text]
- Schachner T, Bonaros N, Ruetzler E, Weidinger F, Oehlinger A, Laufer G, Friedrich G, Bonatti J. Myocardial enzyme release in totally endoscopic coronary artery bypass grafting on the arrested heart. J Thorac Cardiovasc Surg 2007;134:1006-1011.[Abstract/Free Full Text]
- Al-Rawi PG, Kirkpatrick PJ. Tissue oxygen index: thresholds for cerebral ischemia using near-infrared spectroscopy. Stroke 2006;37:2720-2725.[Abstract/Free Full Text]
- Hoffman GM. Neurologic monitoring on cardiopulmonary bypass: what are we obligated to do?. Ann Thorac Surg 2006;81:S2373-S2380.[Abstract/Free Full Text]
- LeMaire SA, Ochoa LN, Conklin LD, Widman RA, Clubb Jr. FJ, Undar A, Schmittling ZC, Wang XL, Fraser Jr. CD, Coselli JS. Transcutaneous near-infrared spectroscopy for detection of regional spinal ischemia during intercostal artery ligation: preliminary experimental results. J Thorac Cardiovasc Surg 2006;132:1150-1155.[Abstract/Free Full Text]
- Redlin M, Boettcher W, Huebler M, Berger F, Hetzer R, Koster A, Kuebler WM. 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 2006;82:323-325.[Abstract/Free Full Text]
- Ubbink DT, Koopman B. Near-infrared spectroscopy in the routine diagnostic work-up of patients with leg ischaemia. Eur J Vasc Endovasc Surg 2006;31:394-400.[CrossRef][Medline]
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