Femoral Inflow Research Articles

P50: Save leg: using contralateral femoral inflow for distal perfusion catheter placed for Impella CP

Background: Leg ischemia is a possible complication of percutaneous left ventricular device (Impella CP TM) placement. To avoid leg ischemia in atrisk patients, a distal perfusion catheter (DPC) should be placed. The DPC can be connected to the wire-reaccess port of the Impella CP as an inflow to the DPC to perfuse the leg. However, the wire-reaccess port of the Impella was not designed to bypass arterial blood to the distal limb, but rather for wire passage. We introduced a passive distal perfusion system from the contralateral femoral artery to optimize blood flow to the distal limb. Methods: A 65 year-old female with dilated cardiomyopathy developed refractory ventricular tachycardia. She was taken to the catherization laboratory because of hemodynamic instability requiring high doses of vasopressors. By left heart catheterization, we noted normal coronary arteries with elevated left ventricular end-diastolic pressure (38 mm Hg) and a poor cardiac index. Thus, Impella CP was placed from the right groin to stabilize her hemodynamics. A DCP was placed on right distal femoral artery and connected to the wire-reaccess port of the Impella CP. The leg appeared perfused by DPC via reaccess port in the catherization laboratory; however, despite this as well as appropriate anticoagulation, the leg became ischemic (cold leg, low leg regional saturation) shortly after admission to the ICU, where a lack of flow in the DPC was confirmed. Results: An additional contralateral femoral arterial line was placed. The contralateral femoral arterial line was then connected to the DPC (figure), and the reaccess port of the Impella was capped. Shortly after placement of the new DPC system, the pulse was returned and leg saturation improved. Additionally, leg ischemia during Impella support did not reoccur. Conclusion: A DPC using the Impella CP reaccess port provided inadequate distal flow. When a DPC is indicated during femoral Impella CP use, the contralateral femoral artery should be chosen for inflow cannulation. Figure 1. Impella CP and distal perfusion catheter (DPC) in the right femoral artery. The arterial line in the left femoral artery is feeding DPC in the right femroal artery.

Low-Dose Paclitaxel-Coated Balloon Angioplasty versus Uncoated Percutaneous Transluminal Balloon Angioplasty for Femoropopliteal Peripheral Artery Disease: 6-Month Results in a Tertiary Care Hospital of Central India

Abstract Introduction Superficial femoral and popliteal arteries are the most common locations of peripheral vascular disease (PVD). Endovascular interventional therapy including drug-coated balloon (DEB) angioplasty or percutaneous transluminal angioplasty (PTA) and stenting are important options for treatment of PVD. Aims and Objectives The main objective is to compare the efficacy of DEB over PTA with optional stenting in management of obstructive femoropopliteal lesions in terms of 6-month patency rate. Materials and Methods The clinical experimental study was carried out in a tertiary care center over duration of 2 years. All symptomatic patients having lower limb PVD in femoropopliteal segment were included. Total 37 patients were included in this study in which 16 underwent plain balloon angioplasty (with 3 patients undergoing bare metal stenting [BMS]) and 21 additional underwent DEB angioplasty. Patients with previously intervened lesions, primary lesion failure, major ischemic tissue loss, poor aortoiliac or common femoral inflow, or end-stage kidney disorders were excluded. Result At 1-month follow-up, patency rates in DEB and conventional PTA ± BMS were 85.71% and 87.5%, respectively. On 6-month follow-up, patency rates were found to be 71.4% versus 37.5%, respectively (p = 0.039; significant). In case of occluded lesions, on 6-month follow-up, patency rate in DEB group was higher than that in plain balloon group (66.7% vs. 25%). In both the cohorts, success rate, i.e., patency rates were more in short and intermediate length lesions than long segment lesions. DEB was found to be superior to plain angioplasty with optional stenting in terms of 6-month patency rate.

Deep Veins: Hybrid Procedure for Treatment of Iliofemoral Obstruction

Background Endovascular recanalisation of chronic obstruction of iliofemoral or caval veins gives very good patency. However, patency decreases if the common femoral vein and its side branches are also involved. Endophlectomy during a hybrid procedure can improve outcome and avoid early reocclusion due to restored inflow. The review presents the technical details and the published results of this technique. Results The hybrid procedure combines venous recanalisation and stent angioplasty with endophlebectomy. There have only been 4 studies with more than 10 patients and follow-up between 6 and 24 months. Primary and secondary patency ranges from 0 to 70% and 30 to 93%, respectively, but most patients showed clinical benefit. Conclusion Although there have only been a few studies on the hybrid procedure with endophlebectomy, this technique seems to improve the outcome of venous recanalisation if femoral inflow is disturbed.

Technique and Clinical Outcomes of Combined Stent Placement for Postthrombotic Chronic Total Occlusions of the Iliofemoral Veins

PurposeTo evaluate the technical aspects and early clinical results of combined stent placement for the management of postthrombotic syndrome (PTS) in chronic total occlusions (CTOs) of the iliofemoral veins. Materials and MethodsA total of 81 consecutive patients (mean age, 57 y; 37 men; 81 limbs; 65 left limbs) with postthrombotic CTO of the iliofemoral veins treated with combined stent placement in a single institution from January 2013 to December 2014 were retrospectively analyzed. Wallstents were used for femoral inflow and E-Luminexx stents for iliac outflow. Technical aspects, quality of life (QOL), stent patency, and Villalta scores were recorded at follow-up. Primary, primary assisted, and secondary patency rates were estimated with Kaplan–Meier methods with the log-rank test. ResultsPercutaneous recanalization was successful in 77 of 81 limbs (95.1%). Stents were deployed in all iliofemoral occlusions, with two stents in 63 lesions (77.8%) lesions and three stents in 18 lesions (22.2%). Venous perforation occurred in 32 patients (37.4%) and was resolved in all cases after stent placement. Back pain occurred during balloon angioplasty (93.8%) and persisted after stent placement in 56.8% of patients. However, the symptoms were self-limiting without further therapy. QOL and Villalta scores were significantly improved during a median follow-up of 19 months (range, 1–38 mo; P < .01). The 2-year primary, primary assisted, and secondary cumulative stent patency rates were 81.5%, 91.4%, and 93.8%, respectively. ConclusionsCombined stent placement is an effective, safe, and feasible method of management of PTS in iliofemoral CTO until commercial venous stents designed for PTS become available.

The predictive value of haemodynamic parameters for outcome of deep venous reconstructions in patients with chronic deep vein obstruction - A systematic review.

Objective The aim of this study was to investigate the predictive value of haemodynamic parameters on success of stenting or bypass surgery in patients with non-thrombotic or post-thrombotic deep venous obstruction. Methods EMBASE, MEDLINE and trial registries were searched up to 5 February 2016. Studies needed to investigate stenting or bypass surgery in patients with post-thrombotic obstruction or stenting for non-thrombotic iliac vein compression. Haemodynamic data needed to be available with prognostic analysis for success of treatment. Two authors, independently, selected studies and extracted data with risk bias assessment using the Quality in Prognosis Studies tool. Results Two studies using stenting and two using bypass surgery were included. Three investigated plethysmography, though results varied and confounding was not properly taken into account. Dorsal foot vein pressure and venous refill times appeared to be of influence in one study, though confounding by deep vein incompetence was likely. Another investigated femoral-central pressure gradients without finding statistical significance, though sample size was small without details on statistical methodology. Reduced femoral inflow was found to be a predictor for stent stenosis or occlusion in one study, though patients also received additional surgery to improve stent inflow. Data on prediction of haemodynamic parameters for stenting of non-thrombotic iliac vein compression were not available. Conclusions Data on the predictive value of haemodynamic parameters for success of treatment in deep venous obstructive disease are scant and of poor quality. Plethysmography does not seem to be of value in predicting outcome of stenting or bypass surgery in post-thrombotic disease. The relevance of pressure-related parameters is unclear. Reduced flow into the common femoral vein seems to be predictive for in-stent stenosis or occlusion. Further research into the predictive effect of haemodynamic parameters is warranted and the possibility of developing new techniques that evaluate various haemodynamic aspects should be explored.

Arteriovenous fistula geometry in hybrid recanalisation of post-thrombotic venous obstruction.

Post-thrombotic obstruction can be adequately treated by percutaneous transluminal angioplasty and stenting. When post-thrombotic trabeculations extend below the femoral confluence, proper inflow can be facilitated by endophlebectomy and creation of an arteriovenous fistula. The aim of this study was to investigate whether it is more favourable to place the arteriovenous fistula at the cranial or caudal end of the endophlebectomy to prevent stenosis or occlusion. We retrospectively analysed the clinical data of all patients who underwent a hybrid procedure in our two centres. Demographics, interventional details and post-operative imaging were collected. Data on 42 limbs with cranially and 23 limbs with caudally placed arteriovenous fistulas were collected. Post-thrombotic disease of the profunda femoral vein alone or in combination with the femoral vein was observed more often in the cranial group. The caudal group more often received a smaller sized and straight polytetrafluoroethylene fistula, while the cranial group comprised a significantly higher amount of stented segments. Logistic regression showed that only reduced femoral inflow (hazard ratio 2.934 (95%CI, 1.148-7.494)) was a significant predictor of stent stenosis and/or occlusion. Logistic regression for risk of occlusion showed a significant influence of stent-related complications (hazard ratio 4.691 (95%CI, 1.205-18.260)) and a tendency towards influence of arteriovenous fistula geometry in favour of the cranially placed fistula. Placement of the arteriovenous fistula in the cranial part of the endophlebectomy during hybrid recanalisation may result in a more favourable outcome, yet this tendency was not statistically significant. Moreover, femoral inflow is pivotal in maintaining patency and should thus be adequately assessed pre-operatively.

Outcomes of Aortic Arch Replacement Performed Without Circulatory Arrest or Deep Hypothermia.

Aortic arch replacement using standard techniques, including deep hypothermic circulatory arrest and selective antegrade cerebral perfusion, is still associated with significant mortality and cerebral morbidity. We have previously described the "branch-first" technique that avoids circulatory arrest or profound hypothermia with excellent outcomes. We now describe our clinical experience with a larger cohort of patients as well as follow-up of our earlier results. We also describe a further technical simplification to this technique. From 2005 to 2010, 43 patients underwent a "branch-first continuous perfusion" technique for aortic arch replacement. In this technique, arterial perfusion is peripheral, usually by femoral inflow. Disconnection of each arch branch and anastomosis to a perfused trifurcation graft proceeds sequentially from the innominate to the left subclavian artery, with uninterrupted perfusion of the heart and viscera by the peripheral cannula. In the first cohort perfusion to the trifurcation graft was by right axillary cannulation. Since 2009, a modification was introduced such that perfusion is supplied directly by a sidearm on the trifurcation graft. This was used in the last 18 patients of this series. After reconstruction of the debranched arch and ascending aorta, the common stem of the trifurcation graft is anastomosed to the arch graft. In this series, there were 27 males, and mean age was 63 ± 13 years. Fifteen cases (35%) were performed with urgent/emergent priority. Nineteen patients (44%) were operated for aortic dissection, and the remainder for aneurysms. Seven patients (16%) had previously undergone a cardiac surgical procedure. There were two (4.7%) early mortalities while one patient (2.3%) experienced a permanent stroke. One patient (2%) required mechanical support while three (7%) required hemofiltration for renal support. Extubation was achieved within 24 hours in 21 patients (49%) while 19 (42%) were discharged from the Intensive Care Unit (ICU) within two days. Eight patients (19%) did not require any transfusion of red cells or platelets. Mean follow-up duration was 21 ± 19 months and was 100% complete. At three years, survival was 95 ± 3.2%. No patients required subsequent aortic reoperation during this early follow-up period. This modified branch-first continuous perfusion technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Our early experience is encouraging although greater numbers and longer follow-up will reveal the full potential of this approach.

Continuous perfusion "Branch-first" aortic arch replacement: a technical perspective.

The following video, along with the in-depth perspective article published elsewhere in this issue, aims to take you through the significant steps and the theoretical aspects of aortic arch replacement using the “Branch-first” continuous perfusion technique (Video 1). Video 1 Continuous perfusion “Branch-first” aortic arch replacement: a technical perspective In essence the procedure consists of 5 major steps: Establishment of cardiopulmonary bypass using femoral inflow and moderate hypothermia; Serial disconnection and reconstruction of each arch branch (proceeding from innominate to left subclavian) using a trifurcation arch graft with a perfusion side arm port (TAPP graft, Vascutek Ltd., Renfrewshire, Scotland, UK). Following completion of the innominate anastomosis, the perfusion side arm port is used for selective antegrade cerebral perfusion for the remainder of the procedure; Clamping of the proximal descending aorta and construction of the distal arch anastomosis; Completion of aortic root reconstruction; Connection of the common stem of the trifurcation graft to the ascending aortic graft. Collateral network and individual proximal arch branch clamping A basic principle of the “Branch-first” technique is the richness of the collateral network that exists between the 3 arch branches and between the arch branches and the upper and lower body. Apart from the circle of Willis, there are a number of extra-cranial collateral channels that augment cerebral perfusion during individual clamping of each branch vessels (1,2). These collateral channels include: Those between the external and internal carotid arteries; The right and the left carotid arteries; The upper and lower body; The subclavian and carotid arteries. These extracranial collaterals allow for a short period of occlusion of one branch while the other two branches perfuse its territory. Typically with this technique, anastomotic times for each individual branch vessel are performed in approximately 10 minutes and we rarely see changes in ipsilateral cerebral oxygenation during this period. On the infrequent occasion that this does occur, alteration of systemic or head circuit flows generally brings cerebral oxygenation back to baseline levels.

Technique for repair of suprarenal and thoracoabdominal aortic aneurysms

Suprarenal and thoracoabdominal aortic aneurysms represent significant surgical challenges. For patients with associated aortic dissections, current endovascular technology has not been matured to address branch reconstructions that derive from separate lumens, making open surgical reconstruction the only proven method for repair. The required exposures of the thoracoabdominal aorta are expansive, and the extent of aortic replacement mandates efficient technique. Furthermore, a well-orchestrated team of surgeons, nurses, anesthesiologists, and perfusionists are all integral to achieving good outcomes and keeping operative courses tightly managed. Techniques to address extensive aneurysms of the thoracoabdominal aorta are reviewed in detail here, and videos are provided on The Journal website to show relevant anatomical features.

Patency and limb salvage rates after distal revascularization to unclampable calcified outflow arteries

Purpose Severe circumferential calcification of the outflow artery during lower-extremity distal revascularization is considered a poor prognostic factor for bypass graft patency. The aim of this study was to assess the influence of circumferential infrapopliteal arterial calcification on bypass graft patency and limb salvage rates, comparing patency and limb salvage rates in unclampable calcified distal outflow arteries with those observed in uncalcified distal outflow arteries. Methods From July 1990 to July 1997, of 441 distal bypass graft procedures performed by the same surgeon, 69 (16%, group I) involved unclampable calcified outflow vessels, whereas 83 (19%, group II) outflow vessels were uncalcified; the other 289 (65%) had varying intermediate degrees of calcification and were not included in this analysis. All procedures were performed for limb-threatening ischemia and involved standard vein patch angioplasty of the distal anastomotic site, irrespective of the conduit used. Primary and secondary patency, limb salvage, and survival rates were assessed by using Kaplan-Meier analysis. Results Groups were similar with regard to age, sex, and atherosclerotic risk factors except for a higher incidence of diabetes mellitus (88% vs 65%, P = .001) and renal failure (17% vs 5%, P = .01), including dialysis dependency ( P = .01) in group I. Gangrene as an indication for surgery was statistically more frequent in group I (49% vs 29%, P = .01). The distal anastomotic locations and types of conduit involved were similar in the two groups. The femoral inflow level was used more often in group II (63% vs 38%, P = .003), the popliteal in group I (32% vs 17%, P = .03). Follow-up ranged from 30 days to 144 months, with a mean of 69 months. None of the patients were lost during the follow-up period. None of the patients died during the perioperative (30-day) period. Primary patency rates at 1, 3, and 5 years were 84%, 65%, and 52% for group I and 89%, 76%, and 69% for group II ( P = .07.). Secondary patency rates at 1, 3, and 5 years were 96%, 82%, and 78% for group I and 96%, 85%, and 82% for group II ( P = .58). Limb salvage rates at 1, 3, and 5 years were 93%, 83%, and 81% for group I and 97%, 90%, and 86% for group II ( P = .39). Conclusions Distal revascularization to unclampable, severely calcified outflow arteries can achieve much the same results to those obtained in uncalcified outflow arteries. A circumferentially calcified distal recipient artery should not be considered a major obstacle to an attempt at limb salvage bypass graft surgery.

Femoroaxillary Bypass for Cerebral Ischemia

The case of a 69-year-old woman with a complicated history of intrathoracic aortic arch and arch vessel reconstruction is reported. She presented with occlusion of multiple arch vessels and symptoms of cerebral ischemia. A remote femoral inflow route was used for revascularization of the arch vessels owing to the hostile nature of the arch reoperative field.

Enkephalin lowers vascular resistance in dog hindlimb via a peripheral nonlimb site

The intravenous administration of methionine enkephalin in anesthetized dogs produces an abrupt decline in mean arterial pressure, left ventricular pressure, and the maximal rate of left ventricular pressure development. All of these changes are prevented by receptor blockade with the opiate antagonist, naloxone. To evaluate peripheral vascular contributions to these responses, experiments were conducted in a constant pressure-isolated perfused hindlimb. In this model, the sharp decline in mean arterial pressure associated with enkephalin injection (5 micrograms/kg iv) coincided with an equally sharp decline in vascular resistance (rise in blood flow) in the hindlimb. Both were blocked by naloxone pretreatment (1 mg/kg). When equal doses of enkephalin were administered directly into the femoral inflow (external iliac artery), both arterial pressure and hindlimb flow responses were all but eliminated. This observation ruled out significant direct vascular interactions in the response and indicated a site of action outside the hindlimb. Additional catheters were placed in the bracheocephalic artery and descending aorta to permit the comparison of arterial injections conducted, respectively, into the cerebral or abdominal circulations. Injections introduced into the descending aorta consistently produced the greatest response, followed by injections (in descending order of effectiveness) into the jugular, the brachiocephalic, and external iliac. The response in the hindlimb vasculature was initiated at a site somewhere between the diaphragm and terminal aorta. The vascular response to enkephalin was subsequently eliminated by blocking ganglionic transmission with the nicotinic antagonist mecamylamine. These observations suggest that the opioids probably interrupt local vasomotor traffic via opiate receptors in regional sympathetic ganglia or in the spinal cord.

Retrograde aortic dissection during cardiopulmonary bypass

Femoral artery perfusion for cardiopulmonary bypass is still employed for reoperation, procedures involving the thoracic aorta, and partial bypass in critical patients. Retrograde aortic dissection is the most significant complication of femoral perfusion. The reported incidence is from 0.6% to 14% with a mortality of 66%. Most of the deaths occurred in patients in whom the dissection was not recognized , or in whom the dissection was recognized but not treated appropriately. Our experience with retrograde dissection totals six patients of 640 (0.9%) in whom femoral inflow was used. Four of the six patients survived the dissection. Sudden increase in extracorporeal line pressure shortly after beginning cardiopulmonary bypass associated with decreased venous return, dampened radial arterial pressure, and the abrupt appearance of a bluish, bulging ascending aorta establishes the diagnosis. Survival is enhanced if cardiopulmonary bypass is promptly discontinued, aortic cannulation established, and bypass reinstituted with the induction of profound hypothermia. Circulatory arrest may then be employed to repair the false passage. In this series the proposed operation was completed in all six patients.

Effects of Aortic Balloon Pumping during Cardiopulmonary Bypass on Myocardial Perfusion, Metabolism, and Contractility

This study was undertaken to determine if the production of pulsatile flow by the intra-aortic balloon pump during cardiopulmonary bypass has any beneficial effect on coronary flow, regional myocardial flow, myocardial metabolism, and left ventricular function. Thirty-six conditioned dogs were subjected to one hour of total normothermic cardiopulmonary bypass. They were divided into the following five groups: (1) controls, beating heart and femoral inflow; (2) balloon, beating heart, and femoral inflow; (3) balloon, beating heart, and aortic inflow; (4) control, fibrillating heart and femoral inflow; and (5) balloon, fibrillating heart, and femoral inflow. Total coronary flow, left ventricular flow, coronary sinus flow, and the endocardial-to-epicardial flow ratio increased in group 3. This increase in flow may have been in part due to increased resistance to flow in the descending aorta by the balloon. No differences in flow were noted in the other groups, all of which were perfused via the femoral artery. No significant differences in myocardial metabolism or left ventricular contractility could be demonstrated between balloon-treated and control groups in these normal hearts.

Senile arterial changes in a child aged seven weeks: Hughes, F. W. Terrell, and Perry, C. Bruce: Bristol Med. Chir. J. 46: 219, 1929

This study was undertaken to determine if the production of pulsatile flow by the intra-aortic balloon pump during cardiopulmonary bypass has any beneficial effect on coronary flow, regional myocardial flow, myocardial metabolism, and left ventricular function. Thirty-six conditioned dogs were subjected to one hour of total normothermic cardiopulmonary bypass. They were divided into the following five groups: (1) controls, beating heart and femoral inflow; (2) balloon, beating heart, and femoral inflow; (3) balloon, beating heart, and aortic inflow; (4) control, fibrillating heart and femoral inflow; and (5) balloon, fibrillating heart, and femoral inflow. Total coronary flow, left ventricular flow, coronary sinus flow, and the endocardial-to-epicardial flow ratio increased in group 3. This increase in flow may have been in part due to increased resistance to flow in the descending aorta by the balloon. No differences in flow were noted in the other groups, all of which were perfused via the femoral artery. No significant differences in myocardial metabolism or left ventricular contractility could be demonstrated between balloon-treated and control groups in these normal hearts.