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Augmented femoral venous return
Augmented Femoral Venous Return Lynn Solomon, MD, Francis P. Sutter, DO, Scott M. Goldman, MD, John M. Mitchell, BS, CCP, and Kevin Casey, MD Lankenau Hospital and Medical Research Center, Wynnewood, Pennsylvania We present a technique of femoral cardiopulmonary bypass that allows excellent venous drainage. This is accomplished by augmenting the venous return with a centrifugal pump. (Ann Thorac Surg 1993;55:1262-3)
Tip in
Oxygenator
Venous t--
e have developed a technique of femoral cardiopulmonary bypass in which venous drainage is improved by augmenting venous return with a centrifugal Pump.
The right femoral vein is accessed percutaneously just inferior to the inguinal ligament, and a 150-cm guidewire is threaded into the vein. Via Seldinger technique, a 21F DLP venous cannula (DLP, Inc, Grand Rapids, MI) is inserted and positioned at the level of the right atrium. Proper positioning at the atrial level is crucial. The arterial venous loop (Fig 1) is modified as follows: A %-inch venous line is connected to the inlet of a centrifugal pump head, which is positioned just proximal to a hard-shell venous reservoir. A flow probe for the venous limb is located between the centrifugal pump head and the venous reservoir, allowing monitoring and adjustment of augmented return. Decannulation requires only removal of the catheter with a simple figure-of-8 skin suture and a short period of manual compression. Using augmented venous return, flow rate indices in the range of 2.4 to 2.6 L min-' m-' have been consistently obtained. Decompression of the right ventricle is both visually assessed and confirmed by monitoring of pressures with a pulmonary artery catheter.
-
Results
w 1
Accepted for publication Jan 28, 1993 Address reprint requests to Dr Sutter, 558 Lankenau Medical Building East, 100 Lancaster Ave West of City Line, Wynnewood, PA 19096.
Society of Thoracic Surgeons
Roller
IT 1
Fig 1 . Augmented venous return. (Art. = arterial; RA = right atrium.)
flows are seen in Figure 2. We have had no complications from this technique, including either groin hematomas or clinically significant hemolysis.
Comment Femorofemoral bypass is an important technique in aortic dissections, redo coronary artery bypass grafting, thoracic aneurysm repair, and, most recently, cardiopulmonary support or assisted cardiac catheterization procedures. Standard femoral venous cannulation has a limited capacity to achieve adequate flow rates secondary to suboptimal venous return. Augmented venous return has several advantages and produces results equivalent to direct right atrial cannulation, with full bypass being easily achieved.
4
Since early 1990 we have used this technique in 54 patients. The procedures range from reoperative coronary artery bypass grafting and aortic dissection to removal of right atrial myxoma. Fourteen patients had warm cardiopulmonary bypass. In no case was it necessary to convert to standard atrial cannulation or to cool the patient because of inadequate flow. Perfusion was always satisfactory, with occasional brief episodes of decreased flow when the heart was being lifted. Our minimudmaximum
0 1993 by The
Centrifugal Pump
Venous Reservoir
Technique
-
Flow Probe
Flow Index (I/min/MP) __
3.5 3
~~
0
5
10
15
20
25
30
35
45
40
50
55
60
Patient Number (N=54) High and
Low
Fig 2. Flow index range using augmented femoral venous return. 0003-4975/93/$6.00
Ann Thorac Surg
1993;55:1262-3
Cardiac decompression before sternotomy is possible to safeguard against iatrogenic injury upon entering the chest. This decision can be made preoperatively, based on clinical grounds. In other cases, stemotomy and dissection are undertaken, but with the femoral venous wire in place so that, if necessary, full cardiopulmonary bypass via the femoral route can be undertaken in seconds. Two other advantages in reoperative procedures are avoiding atrial cannulation, which obviates the increased risk of dissecting an extremely adherent atrium, and avoiding a patent right vein graft.
HOW TO DO IT SOLOMON ET AL AUGMENTED FEMORAL VENOUS RETURN
1263
Finally, with increased use of cardiopulmonary support systems in the catheterization laboratory, augmented venous return allows for a rapid and efficient conversion to full bypass, without necessitating recannulation. In summary, full cardiopulmonary bypass via femoral cannulation is easily established with a simple modification of the arterial venous loop bypass system using a centrifugal pump and flow meter attached to the venous line. Using this augmented venous return, flow rates and right heart decompression are obtained that equal those of standard atrial-aortic cannulation.
REVIEW OF RECENT BOOKS
Practical Thoracoscopy By Christian Boutin, lean Viallat, and Yossef Aelony Berlin, Springer-Verlag, 1991 112 pp, illustrated, $125.00 Reviewed by lames L. Nielsen, M D With the recent expansion of interest in thoracoscopy and the development of new techniques and equipment, this monograph appears obsolete. Written by a group including one of Europe’s premier proponents of thoracoscopy, Practical Thoracoscopy provides the reader with a general overview of thoracoscopy as practiced by a pulmonologist, which, judging by the response of attendees at the recent meeting of The Society of Thoracic Surgeons, is a matter of some concern. In the introduction, the authors state that the techniques of thoracoscopy are ”within the capability of not only surgeons but any physician adept with his hands.” To their credit, the authors maintain the focus of the book on diagnosis and management of pleural disease, with little emphasis on pulmonary parenchymal pathology. Beginning with a discussion of the history of thoracoscopy, the
book moves through a chapter on thoracoscopic equipment, which seems primitive compared with that available to surgeons in the United States. Thoracoscopic techniques are then covered, including descriptions of methods of local anesthesia, adhesiolysis, and use of the yttrium-aluminum garnet laser. The chapter that follows provides a brief mention of the sequelae of thoracoscopic procedures, including a superficial review of the authors’ initial experience. Subsequent chapters deal with the use of thoracoscopy for acute and chronic pleural effusions and spontaneous pneumothorax. The monograph ends with a chapter on other indications for thoracoscopy, including brief discussions of pulmonary biopsy, empyema, mediastinal tumor and lymph node biopsy, sympathectomy, and pericardiectomy. This work has little to recommend it for the thoracic surgeon except for multiple excellent color photographs of various pathologic pleural states. Overall, it is a superficial, outdated treatment of a burgeoning technique that should remain in the hands of those adequately trained to definitively treat the variety of potential pathology encountered during its use.
San Antonio, Texas
Tip in
Oxygenator
Venous t--
e have developed a technique of femoral cardiopulmonary bypass in which venous drainage is improved by augmenting venous return with a centrifugal Pump.
The right femoral vein is accessed percutaneously just inferior to the inguinal ligament, and a 150-cm guidewire is threaded into the vein. Via Seldinger technique, a 21F DLP venous cannula (DLP, Inc, Grand Rapids, MI) is inserted and positioned at the level of the right atrium. Proper positioning at the atrial level is crucial. The arterial venous loop (Fig 1) is modified as follows: A %-inch venous line is connected to the inlet of a centrifugal pump head, which is positioned just proximal to a hard-shell venous reservoir. A flow probe for the venous limb is located between the centrifugal pump head and the venous reservoir, allowing monitoring and adjustment of augmented return. Decannulation requires only removal of the catheter with a simple figure-of-8 skin suture and a short period of manual compression. Using augmented venous return, flow rate indices in the range of 2.4 to 2.6 L min-' m-' have been consistently obtained. Decompression of the right ventricle is both visually assessed and confirmed by monitoring of pressures with a pulmonary artery catheter.
-
Results
w 1
Accepted for publication Jan 28, 1993 Address reprint requests to Dr Sutter, 558 Lankenau Medical Building East, 100 Lancaster Ave West of City Line, Wynnewood, PA 19096.
Society of Thoracic Surgeons
Roller
IT 1
Fig 1 . Augmented venous return. (Art. = arterial; RA = right atrium.)
flows are seen in Figure 2. We have had no complications from this technique, including either groin hematomas or clinically significant hemolysis.
Comment Femorofemoral bypass is an important technique in aortic dissections, redo coronary artery bypass grafting, thoracic aneurysm repair, and, most recently, cardiopulmonary support or assisted cardiac catheterization procedures. Standard femoral venous cannulation has a limited capacity to achieve adequate flow rates secondary to suboptimal venous return. Augmented venous return has several advantages and produces results equivalent to direct right atrial cannulation, with full bypass being easily achieved.
4
Since early 1990 we have used this technique in 54 patients. The procedures range from reoperative coronary artery bypass grafting and aortic dissection to removal of right atrial myxoma. Fourteen patients had warm cardiopulmonary bypass. In no case was it necessary to convert to standard atrial cannulation or to cool the patient because of inadequate flow. Perfusion was always satisfactory, with occasional brief episodes of decreased flow when the heart was being lifted. Our minimudmaximum
0 1993 by The
Centrifugal Pump
Venous Reservoir
Technique
-
Flow Probe
Flow Index (I/min/MP) __
3.5 3
~~
0
5
10
15
20
25
30
35
45
40
50
55
60
Patient Number (N=54) High and
Low
Fig 2. Flow index range using augmented femoral venous return. 0003-4975/93/$6.00
Ann Thorac Surg
1993;55:1262-3
Cardiac decompression before sternotomy is possible to safeguard against iatrogenic injury upon entering the chest. This decision can be made preoperatively, based on clinical grounds. In other cases, stemotomy and dissection are undertaken, but with the femoral venous wire in place so that, if necessary, full cardiopulmonary bypass via the femoral route can be undertaken in seconds. Two other advantages in reoperative procedures are avoiding atrial cannulation, which obviates the increased risk of dissecting an extremely adherent atrium, and avoiding a patent right vein graft.
HOW TO DO IT SOLOMON ET AL AUGMENTED FEMORAL VENOUS RETURN
1263
Finally, with increased use of cardiopulmonary support systems in the catheterization laboratory, augmented venous return allows for a rapid and efficient conversion to full bypass, without necessitating recannulation. In summary, full cardiopulmonary bypass via femoral cannulation is easily established with a simple modification of the arterial venous loop bypass system using a centrifugal pump and flow meter attached to the venous line. Using this augmented venous return, flow rates and right heart decompression are obtained that equal those of standard atrial-aortic cannulation.
REVIEW OF RECENT BOOKS
Practical Thoracoscopy By Christian Boutin, lean Viallat, and Yossef Aelony Berlin, Springer-Verlag, 1991 112 pp, illustrated, $125.00 Reviewed by lames L. Nielsen, M D With the recent expansion of interest in thoracoscopy and the development of new techniques and equipment, this monograph appears obsolete. Written by a group including one of Europe’s premier proponents of thoracoscopy, Practical Thoracoscopy provides the reader with a general overview of thoracoscopy as practiced by a pulmonologist, which, judging by the response of attendees at the recent meeting of The Society of Thoracic Surgeons, is a matter of some concern. In the introduction, the authors state that the techniques of thoracoscopy are ”within the capability of not only surgeons but any physician adept with his hands.” To their credit, the authors maintain the focus of the book on diagnosis and management of pleural disease, with little emphasis on pulmonary parenchymal pathology. Beginning with a discussion of the history of thoracoscopy, the
book moves through a chapter on thoracoscopic equipment, which seems primitive compared with that available to surgeons in the United States. Thoracoscopic techniques are then covered, including descriptions of methods of local anesthesia, adhesiolysis, and use of the yttrium-aluminum garnet laser. The chapter that follows provides a brief mention of the sequelae of thoracoscopic procedures, including a superficial review of the authors’ initial experience. Subsequent chapters deal with the use of thoracoscopy for acute and chronic pleural effusions and spontaneous pneumothorax. The monograph ends with a chapter on other indications for thoracoscopy, including brief discussions of pulmonary biopsy, empyema, mediastinal tumor and lymph node biopsy, sympathectomy, and pericardiectomy. This work has little to recommend it for the thoracic surgeon except for multiple excellent color photographs of various pathologic pleural states. Overall, it is a superficial, outdated treatment of a burgeoning technique that should remain in the hands of those adequately trained to definitively treat the variety of potential pathology encountered during its use.
San Antonio, Texas