I have enclosed a you tube video link to my technique for femoral cannulation.
If femoral cannulation is not possible, my second choice would be axillary.
I am constantly asked if a CT angio is absolutely required to perform these cases. The answer is NO,NO,and NO.
I know there will be those that will consider this crazy, not “by the book”, or even unethical. I am not saying that it should not be performed, but I have not found it necessary in over 2,000 cases!!! If I suspect severe PVD, then I might consider it. Where has it been “written is stone” that it must be performed before any minimally invasive case? If one utilizes an endo-balloon or performs a TAVR via a femoral platform, then it is necessary. The main reason is because a device is being passed and scraped along the vessel walls and can dislodge mobile plaque. Although, despite even when there is plaque within the aorta, these devices are used.
My question to those that question why not do a CT angio on everyone would be, 1.what will you do with the findings? 2. how do you interpret the findings to guide your operative strategy? 3. How do you really know that the findings are really dangerous and contraindicate cannulation?
I have performed over 2000 cases with this approach and my incidence of stroke is less than 1.5% for all risk groups. I truly believe that the stroke risk is not related to the cannulation technique, but more so to inadequate de-airing or particulate matter in the heart or from aortic cross clamping. We will be publishing our results soon.
Nice Video Joe! I think it’s important to suture the cannulas to the skin as you have done in your video. At the end of the case if the patient requires external cardioversion and the muscle relaxant is suboptimal, the leg can jerk. The suture technique to the skin provides additional peace of mind to prevent problems. I agree pre op CTA is not needed.
Joe can you comment on your technique and protocol for percutaneous venous line placement? Every once in a while I can’t place the venous line via the left femoral vein given the angle of the vein within the abdomen and have been tempted to try the percutaneous approach via the right. I’d like to avoid an incision on the right as the patients pre op cath site is often still fresh. What protocol do you use with regards to heparin reversal and post removal direct pressure? Do you advise against this practice? Thank you for sharing your experiences as they have proven invaluable to me.
Good observation. I do fix the cannula to the skin but mainly to assure that it is exactly where I have initially placed it . Once I fix it , I do not remove it until I am ready to withdraw the cannula. As far as venous cannulation, I try as much as possible to access the left femoral vein, even if the angle is acute. If I have trouble passing the cannula, I will access the right femoral vein. I will use a Cook needle to access the vein (2-3 finger breaths beneath the right femoral crease). It is important to stay away from the crease because it will impede insertion of the actual cannula. Use the blue dilators to sequentially dilate the tract. Once you are able to pass the large white dilator (Big Bertha!) you are granted passage.The only incision will be a 1 cm incision to help pass the 25 Fr. cannula through the skin. At the end of the case, after giving 1/2 of the protamine, I will place a large U-stitch in the skin (semi-deep),remove the venous cannula and hold pressure for 30 minutes. Do not remove that U-stitch until the patient is ready to go home. It will cause a significant hematoma if you do. I will provide a video of this very soon. I can see that you are on top of all the details. You are definitely one of the thought leaders.