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Endoscopic Surgery for Cardiac
Tumours
Abdelrehman Abdelbar and Joseph Zacharias
Abstract
With increasing experience in endoscopic
techniques a sub group of patients who could
benefit from this approach are patients presenting with a diagnosis of cardiac tumours.
These are often picked up as an incidental
finding and once the diagnosis is made early
surgery is warranted. These can provide
challenges to get a team together but if an
institution offers this approach as a routine,
then these cases can be dealt with quickly. In
this chapter we summarise some of the case
series in the literature and present a case to
show the pathway followed. We also include a
video to capture the key steps.
Keywords
Endoscopic cardiac tumoursCardiac
myxomas
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_16. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
A. Abdelbar J. Zacharias (&)
Department of Cardiothoracic Surgery, Lancashire
Cardiac Centre, Blackpool, England
e-mail: a.abdelbar@nhs.net
Papillary fibroelastoma
1 Epidemiology and Pathology
Cardiac neoplasms are extremely rare conditions
which are represented by a small group of patient
population even in large tertiary cardiac surgery
centres [1]. Due to the current status of many of
these being under diagnosed, it is very difficult to
estimate an accurate prevalence in the living
population. The disease load is only obtained
from post-mortem studies. These studies have
shown that primary cardiac tumors are rarer than
secondary deposits with an incidence of 0.05%
and 1% respectively. This percentage does not
reflect the real practice or case load in the cardiac
centres. It is likely that cardiac tumors are
underdiagnosed in the real world of clinical
practice [2]. Despite the advances and the wide
use of cardiac imaging modalities, cardiac
tumors are rarely symptomatic and most patients
have an incidental pick up following on from an
imaging study.
Likewise, to any tumour, cardiac tumours are
classified into primary and secondary tumours.
Primary cardiac tumours are further divided into
benign and malignant.
Benign cardiac tumours include Myxoma
(represents 50% of all primary cardiac tumours),
rhabdomyoma, lipoma, fibroma and angioma.
Malignant cardiac tumours are mainly sarcomas
(e.g. angiosarcoma and rhabdom yosarcoma) or
lymphomas. Secondary cardiac tumours are
usually part of a widespread malignancy which is
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_16
237
238 A. Abdelbar and J. Zacharias
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not only limited to the heart. Metastasis to the
heart is most commonly linked to lymphoma,
leukaemia and melanoma.
Clinical presentation of cardiac tumours is
extremely variable. It depends on the location
and the size of the tumour. Most of the cases will
be asymptomatic, the diagno sis of which is
usually post-mortem. When symp tomatic, cardiac tumours are usually presented by one of
three classic features. This triad is obstruction,
embolic phenomena and constitutional symptoms. Depending on the size and position of the
tumour, the effects on the haemodynamics and
the site of embolisation are determined. For
example, a tumour on the right side of the heart
will cause pulmonary embolic manifestations
while those on the left are more likely to lead to
systemic emboli and its effects. Other presentations might be arrhythmia in case of tumours
invading the myocardium. A tumour invading
the pericardium might cause pericardial effusion
and possible cardiac tamponade.
2 Role of Minimally Invasive
Surgery
Generally speaking, minimally invasive surgery
is still under-performed in cases of cardiac
tumours. This is since cardiac tumours themselves are rare in clinical practice. The increased
availability and utilisation of cardiac echocardiogram has incre ased the number of diagnosed
cases, yet, the overall case load is still under 1%
of the performed cardiac surgery cases in the
United Kingdom. The argument for expanding
the role of minimally invasive surgery is to
obtain both its well-recognised post-operative
benefits and, the comparable or even superior
tumour clearance.
Post-operative benefits of minimally invasive
surgery are well described in the literature [3, 4].
They include faster patient recovery, less blood
loss with consequent less blood transfusion, less
wound complications, shorter intensive care and
overall hospital stays [5, 6]. The morbidity and
mortality were found to be less in minimally
invasive surgery. Benefits of minimally invasive
surgery will extend to post discharge benefits in
terms of shorter rehabilitation requirements and
quicker return to work [7, 8]. All these factors are
likely to support increased execution of minimally invasive surgery for better patient care and
improvements of the wider health care economy.
In terms of tumour clearance, minimally
invasive surgery provides better visualisation of
the intra-cardiac structures which, in turn, results
in more specific excision. The use of high definition and 3D endoscopes has enabled easy
navigation in the difficult access areas such as the
ventricles through the corresponding atrioventricular valves which can give a wider
working area. In contrast, when sternotomy is
utilized, ventricles were accessed through aortic
and pulmonary valves which gives a narrower
field and increases the risk of injury to those fine
valves.
So far, the evidence in terms of minimally
invasive resection of cardiac tumors is still relying on case reports, case series [9] and fewer
meta-analysis papers. Due to the small numbers
and the urgent presentation a randomized control trial is unlikely to be carried out and
hence high grade evidence will always be lacking
[10].
Some case series have shown the results of
MICS approach for resection of cardiac tumors to
be excellent. For example, our experience [11]
reported the results of 20 patients. This case
series showed 18 patients with left atrial myxoma
and two with left ventricular fibroelastoma. We
highlighted the safety of the procedure with no
mortality, stroke or conversion to sternotomy. No
recurrence of the tumors was reported. Likewise,
Deshpande et al. reported more variable tumor
pathologies and sites [9]. Their case mix showed
right and left atrial myxomas, aortic valve fibroelastoma, tricuspid valve intravenous
leiomyoma with inferior vena cava involvement
and plexiform tumor of the sinoatrial node. They
have reported no post-operative complications
with no recurrence in 27 patients for a median
follow up for 3.4 ± 2.7 years. Bianchi et al.
reported 30 patients who underwent excision of
left atrial myxoma via MICS approach with no
hospital mortality or stroke. They have
Endoscopic Surgery for Cardiac Tumours 239
experienced no recurrence in a follow up median
of 55.6 ± 32.3 months [8].
While the previously mentioned studies lack
comparison with MS, some other teams reported
their comparative results in both MICS and MS.
Lee et al. compared their retrospective results of
143 MS and 63 MICS patients (total 203
patients) [5]. In this study, they have selected
only patients with cardiac myxoma and excluded
patients with any accompanied cardiac pathologies including valve haemodynamic pathologies.
They concluded the superiority of the MICS
approach in terms of blood transfusion and
postoperative arrythmia. They did not find a
significant difference in the post-operative ventilation or hospital stays. They have also reported
a longer cardiopulmonary bypa ss and cross
clamp times in the MICS group which did not
reflect on the post-operative results. Conversely,
Iribarne et al. did not find that CBP and cross
clamp times were longer in the MICS than in MS
[6]. They argued that MICS excision of cardiac
tumors is performed by experienced MICS teams
with already a large MICS valve practice. In the
same study, which included 36 MS and 38 MICS
(total 74 patients), they have also reported a
shorter hospital stay and freedom of recurrence
for a mean time of 4.8 years. Pineda et al.
reported the results of 39 patients (22 MICS and
17 MS) [7]. They have concluded that with
similar outcome in terms of post-operative
complications, MICS poses better utilization of
resources because of the associated shorter ICU
and hospital stays in these case series.
Moscarelli et al. performed the first metaanalysis to compare the outcome between MICS
and MS in treating cardiac tumours. They analysed 653 procedures, majority of them were
cardiac myxoma (601 patients) [4]. They have
concluded excellent outcome of the MICS
approach comparable to MS approach or even
superior despite the longer CBP and cross clamp
times. Tumour size did not influence the choice
of the surgical approach, but they found some
hesitation from some surgeons to perform MICS
in case of right atrial tumour to avoid tumour
fragmentation during cannulation. There was
also no conversion in the MICS group which
signifies the safety of the procedure and the role
of surgical experience with MICS before considering it.
3 Case Scenario
In this section, we will show a step wise
approach to a straightforward confirmed case of
left atrial myxoma in regard to preoperative,
intra-operative and post-operative steps.
To make this case more challenging, we
picked up a female patient with breast implants.
Preoperative imaging:
To decide the suitability of any patient to the
MICS, there are a few multi-modality imaging
which would help. Some of them can be done
intra-operatively eg TOE and groin US.
Echocardiogram:
• Final confirmation of diagnosis.
• Valvular lesions if any.
• Strategy of myocardial preservation. (Table 1)
Role of intra-operative TOE will be discussed in
the intraoperative section.
Contrast enhanced CT scan:
• Exclude extra-cardiac tumors.
• Cannulation strategy:
– Suitable femoral vessels:
Good size femoral arteries with acceptable
course eg no tortuosity.
Freedom of any venous abnormality eg
thrombosed femoral vein.
– Healthy aorto-vascular tree:
No calcifications
– Ascending aorta:
Suitable for using Endo-aortic clamp.
• Right pleural pathology/adhesions.
• Freedom from coronary artery flow limiting
lesions (if ECG gated CT scan is available).
240 A. Abdelbar and J. Zacharias
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Table 1 Aortic occlusion
options
Endo-ballon clamp Yes No No
External cross clamp Yes Yes No
Beating heart Yes Yes No
Coronary artery angiogram:
• Freedom from flow limiting lesions.
• Can provide an idea about the aorto-vascular
tree and the femoral vessels.
Intraoperative:
Anaesthetic consideration:
This going to be discussed in detail in other
chapters but to summarise:
• Single lumen endotracheal tube with a bronchial blocker (right bronchus)
• Central venous catheter
• Radial arterial line catheter:
– In case of using the endo-aortic balloon
clamp, both radial arteries should be used
to monitor occlusion of the any of the great
vessels.
No AR Mild AR Moderate AR
• Groin and chest US:
Final check
– Femoral vessels size and calcifications
– Distance from the skin
– Pleural adhesions
• Mark the MS site and label the rib spaces. (see
Video)
• Expose both groins and the MS site when
patient is draped.
Cannulation:
Detailed cannul ation strategy is described in
other chapters. So, we will provide tips and tricks
for MICS cannulation.
These flow diagrams show the different possibilities that can rise in case of atrial myxomas.
(Flow diagram 1 and 2).
Tips and tricks in case of femoral cannulation:
(see Video 1).
Surgical positioning and set up:
• Supine position with 30-degree tilt towards
the left side. This can be achieved using an
inflatable bag below the right-side 4th intercostal space.
• Skin incision is better if performed 1 inch
above the femoral crease:
– Less wound complications.
– Larger caliber of the femoral vessels.
• Expose only the front service of the vessels to
avoid wound complications.
Endoscopic Surgery for Cardiac Tumours 241
Flow diagram: 1
Flow diagram: 2
• Arterial cannulation:
– Always split the arterial inflow line. In case
the contralateral groin cannulation/central
cannulation is required.
– TOE live monitoring of the descending
aorta until full flow is achieved.
– Arterial inflow pressure never to exceed
300 mmHg. If so, bifemoral cannulation.
• Venous cannulation:
– Live monitoring of the wire and cannula
until cannula is in place.
• Generally: never force the guide wires.
242 A. Abdelbar and J. Zacharias
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Video 1 Step by step video of a left atrial myxoma excision (▶ https://doi.org/10.1007/000-a8c)
Surgical procedure:
In this section, a step-by-step video will be provided. But we would like to point out a few
points:
• Main surgical incision:
– This can vary from a small peri-areolar
incision that enters the chest through the
4th intercostal space in case of endoscopic
assisted practice. A larger incision could be
utilised at a more lateral position in case of
direct vision practice or with pleural
adhesions.
– Better to perform muscle splitting instead
of diathermy for less bleeding and better
healing.
• Other utility incisions (within the axillary
lines):
– 2nd intercostal space: in case of using an
external cross clamp.
– 3rd intercostal space: 10 mm port for the
camera.
– 5th or 6th intercostal space: for traction and
CO
line (utility port).
2
• Better to perform surgical incisions before
heparin administration. Wound closure and
ports removal should be perfor med after
reversal of heparin.
• Better to use two drains at the end, pericardial
and right pleural drains.
• It is favored to perform intercostal blocks
before closure. (see video)
Tips, Tricks and Traps:
• In case of right atrial myxoma near the SVC
or IVC, cannulae should be withdrawn to a
position distal to the cavo-atrial junctions to
allow snaring as described before.
• While handling the myxoma, surgeon’s con-
centration should be focused on minimal
manipulation of the actual myxoma to fragmentation and embolization. Instead, finding
the stalk of the myxoma and using it for
manipulation is safer. This can be achieved by
using the external suction gently to retract the
tumor until the stalk is exposed.
• Large myxomas can be retrieved using a tissue retrieval system to avoid fragmentation
with subsequent embolization and seeding.
Endoscopic Surgery for Cardiac Tumours 243
Post-operative:
Beside the routine post-operative care, a few
points are considered in case of the MICS:
• Immediate post-operative chest Xray to check
right lung expansion and pleural collection in
case of bleeding.
• Drains can be removed as per the local protocol. If there is still high output, pericardial
drain to be removed in 24 h and right pleural
one to be kept in.
• Look out for damage to the phrenic nerve as
post operative atelectasis at the right lower
lobe can also present with a raised right
hemidiaphragm.
• Despite small incisions the pain around the
drain sites can be troublesome so the earlier
the drains can come out the better for patient
to get involved with Physiotherapy and
mobilisation.
• Increasingly we are putting the right sided
chest drain on a portable suction device so
that patients can mobilise easier with the
drains left in.
References
1. Moscarelli M, Rahouma M, Nasso G, Di Bari N,
Speziale G, Bartolomucci F, Pepe M, Fattouch K,
Lau C, Gaudino M. Minimally invasive approaches
to primary cardiac tumors: a systematic review and
meta-analysis. J Card Surg. 2021;36(2):483–92.
2. Centofanti P, Di Rosa E, Deorsola L, Dato GM,
Patane F, La Torre M, Barbato L, Verzini A,
Fortunato G, di Summa M. Primary cardiac tumors:
early and late results of surgical treatment in 91
patients. Ann Thorac Surg. 1999;68(4):1236–41.
3. Pineda AM, Santana O, Zamora C, Benjo AM,
Lamas GA, Lamelas J. Outcomes of a minimally
invasive approach compared with median sternotomy
for the excision of benign cardiac masses. Ann
Thorac Surg. 2011;91(5):1440–4.
4. Moscarelli M, Casula R, Speziale G, Athanasiou T.
Can we use minimally invasive mitral valve surgery
as a safe alternative to sternotomy in high-risk
patients? Interact Cardiovasc Thorac Surg. 2016;22
(1):92–6.
5. Lee HP, Cho WC, Kim JB, Jung SH, Choo SJ,
Chung CH, Lee JW. Surgical outcomes of cardiac
myxoma: Right minithoracotomy approach versus
median sternotomy approach. Korean J Thorac
Cardiovasc Surg. 2016;49(5):356.
6. Iribarne A, Easterwood R, Russo MJ, Yang J,
Cheema FH, Smith CR, Argenziano M. Long-term
outcomes with a minimally invasive approach for
resection of cardiac masses. Ann Thorac Surg.
2010;90(4):1251–5.
7. Pineda AM, Santana O, Cortes-Bergoderi M, Lamelas J. Is a minimally invasive approach for resection
of benign cardiac masses superior to standard full
sternotomy? Interact Cardiovasc Thorac Surg.
2013;16(6):875–9.
8. Bianchi G, Margaryan R, Kallushi E, Cerillo AG,
Farneti PA, Pucci A, Solinas M. Outcomes of videoassisted minimally invasive cardiac myxoma resection. Heart Lung Circ. 2019;28(2):327 – 33.
9. Deshpande RP, Casselman F, Bakir I, Cammu G,
Wellens F, De Geest R, Degrieck I, Van Praet F,
Vermeulen Y, Vanermen H. Endoscopic cardiac
tumor resection. Ann Thorac Surg. 2007;83
(6):2142–6.
10. Ravikumar E, Pawar N, Gnanamuthu R, Sundar P,
Cherian M, Thomas S. Minimal access approach for
surgical management of cardiac tumors. Ann Thorac
Surg. 2000;70(3):1077–9.
11. Kenawy A, Abdelbar A, Zacharias J. Minimally
invasive resection of benign cardiac tumors. J Thorac
Dis. 2021;13(3):1993.
Cannulation Techniques
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for Cardiopulmonary Bypass
in Endoscopic Cardiac Surgery
Karel M. Van Praet, Markus Kofler,
and Jörg Kempfert
Abstract
Extracorporeal circulation throughout minimally invasive cardiac surgery (MICS) is
often provided by peripheral artery cannulation but is mainly performed through surgical
cutdown. Percutaneous placement of cannulas
is assisted by vascular closure devices yet
their advantages to MICS are still disputed.
Hospital stay, operation time and groin complications have been substantially reduced
through percutaneous groin cannulation using
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_17. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
K. M. Van Praet (&) M. Kofler J. Kempfert
Deutsches Herzzentrum der Charité (DHZC),
Department of Cardiothoracic and Vascular Surgery,
Augustenburger Platz 1, 13353 Berlin, Germany
e-mail: vanpraet@dhzb.de;
karel.van-praet@dhzc-charite.de;
karel.vanpraet@gmail.com
J. Kempfert
e-mail: kempfert@dhzb.de
K. M. Van Praet M. Kofler J. Kempfert
Charité – Universitätsmedizin Berlin, corporate
member of Freie Universität Berlin,
Humboldt-Universität zu Berlin, Charitéplatz 1,
10117 Berlin, Germany
DZHK (German Center for Cardiovascular
Research), Partner Site Berlin, Berlin, Germany
vascular closure devices for establishing cardiopulmonary bypass in MICS. The outstanding complications, however, are mainly of
vascular nature versus wound infection and
lymph fistulae with open surgical cutdown. It
is of paramount importance to master a variety
of cannulation techniques for safe perfusion
strategy and operation. The operative techniques for MICS have developed greatly over
the past decade to include a wide demographic
of patients. Our aim is to describe numerous
cannulation strategies and their application
and use in different minimally invasive
procedures.
Keywords
Cardiac surgeryCannulationTechnique
Open surgicalPercutaneousCutdown
Cardiopulmonary bypassMitral valve
Tricuspid valveMinimally invasive surgery
Endoscopic surgery
1 Introduction
There are clear advantages in the adoption of
minimally invasive cardiac surgery (MICS); a
scaling down in length of stay, usage of blood
products, reduction of postoperative pain and
neurological deficit all resulting in overall
improvement of recovery and outcomes. MIC
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_17
245
246 K. M. Van Praet et al.
surgery is a collaboration of innovative surgical
techniques performed through a small incision and
entails less surgi cal trauma than full sternotomy
conventional cardiac surgery. The limitations of
the MICS surgical field elicit essential adaptations
of surgical technology, instrumentation, and cannulation strategy. When applying MICS techniques, a deep and comprehensive grasp of
various cannulation strategies and their application to a wide spectrum of diseases and patients is
required. The appropriate strategy for the necessary cannulation, allowing for optimal exposure
and ease of operation, will depend entirely on the
surgical approach. MICS procedures are broad
and therefore need a wide array of cannulation
options as opposed to conventional sternotomybased surgery that solely uses the central ascending aortic cannulation with right atrial or bicaval
cannulation. Typical MICS techniques include
performing an upper hemisternotomy, lower
hemisternotomy, and a right anterolateral minithoracotomy. Regarding hemisternotomy, some
surgeons may choose percutaneous femoral
venous cannulation in combination with central
arterial cannulation as opposed to the conventional central arterial and venous cannulation.
A completely femoral platform may also be
implemented. Minithoracotomy-based techniques
however often need alternative cannulation
strategies.
2 Arterial Cannulation
When a patient is placed on cardiopulmonary
bypass (CPB) the initial consideration is not only
the cannulation size but also the cannulation site
[1]. This is influenced by the presence of disease
within the artery, the artery size and the patient’s
body surface area (BSA). It is preferred to cannulate the femoral artery for peripheral cannulation and select the cannula size based on BSA [1].
For a BSA of <1.7, a 15F arterial perfusion cannula is chosen, and a 17F cannula for a BSA of
1.7 to 2.1 and when the BSA is >2.1, a 19F
cannula is applied [1]. While on CPB, body
temperature is maintained at around 34 degrees
Celcius. At the authors´institution goal-directedperfusion with DO
-guided perfusion is used.
2
This is helpful in regard to optimal venous drainage as it allows the surgeon to safely reduce the
pump flow to 70–80% of the calculated flow if
required [2]. A 3.2 L flow with a cannula pressure
of 350 mmHg can be reached with cannula sizes
of 15F, 17F, and 19F and 3.5 L or greater flow
rates with a pressure of 350 mmHg, and a 4 L
flow rate with pressures of 300 to 350 mmHg,
respectively [1]. Notwithstanding these smaller
cannula sizes, higher cannula pressures and lower
flow rates, there is no proof of any clinical consequences. An alternative cannulation site is
sometimes required should there be evidence of
significant atherosclerotic disease or a small
femoral artery. A computed tomographic
angiography (CTA) of the chest, abdomen, and
pelvis can reveal such essential information and
has become routine in high-volume programs
with patients undergoing MICS [3]. The authors
believe that CTA should be carried out preoperatively in patients suspected of having aortic
and/or peripheral vascular disease [4]. Although
the benefits are enormously helpful, the disadvantage of a CTA without contrast is that the
subtleties in soft plaque may not be clear and this
is an important risk factor to identify prior to
peripheral cannulation and retrograde arterial
perfusion [2, 5]. An intraoperative finding of
grade 4 to 5 atheroma in the descending aorta
identified with intraoperative transesophageal
echocardiography (TEE) may be a contraindication for retrograde femoral artery perfusion. Safe
candidates for peripheral arterial cannulation are
those with minimal calcified plaque, thrombus or
aneurysmal disease of the aorta [6]. Ipsilateral
peripheral arterial access is contraindicated upon
confirmation of femoral or iliac dissection or
obstructive disease. Should there be any doubt
regarding limb ischemia or prolonged cardiopulmonary times, a distal perfusion catheter may be
inserted, although this is rarely required.
Cannulation Techniques for Cardiopulmonary Bypass in Endoscopic Cardiac Surgery 247
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2.1 Femoral Cannulation
The most prevalent cannulation strategy for
MICS procedures, including minithoracotomy, is
femoral cannulation and can be achieved either
percutaneously or directly via open surgical cutdown [1]. Ultrasound guarantees that the site of
cannulation is in the proximal femoral artery
regarding percutaneous femoral cannulation and
fluoroscopy can also be employed to ensure the
cannula is optimally inserted and placed. The
puncture site is positioned over the femoral head
and access is obtained by puncturing at a point 1/3
of the distance along an oblique line from the
pubic tubercle to the anterior superior iliac spine
[7]. A Seldinger technique is implemented to pass
a guidewire after needle access has been made.
A ProGlide system (Abbott Vascular Devices,
Santa Clara, CA, USA) is then smoothly moved
over the guidewire and is followed by progressive
dilatation and finally passage of the arterial cannula. A suture is situated by this device through
the anterior wall of the artery which is then
tightened following sheath or cannula removal.
The Perclose ProGlide device is approved for
closure of 5F- to 21F-sized arterial sheaths or
cannulas and should therefore only be used on
5 mm or larger vessels. There are other percutaneous closure device options available, including
AngioSeal and Manta devices. The Manta device
(Teleflex, Morrisville, NC, USA) can close arterial access sites after employing 12F to 25F
sheaths. To obtain hemostasis a radiopaque
stainless-steel lock and resorbable collagen and
anchor are sandwiched into the access site [8].
Conversely a collagen plug is used to seal the
arteriotomy in the AngioSeal device (Terumo
Medical Corp., Somerset, NJ, USA). This device,
however, is not acceptable for sufficient arterial
perfusion since it can only be used on 6F or 8F
arterial sheaths or cannulas. A safe alternative to
percutaneous access is direct (open) cannulation
of the femoral artery following cutdown. This
direct exposure allows for palpation of the artery
and avoidance of excessively atherosclerotic
areas as well as allowing for the primary repair of
the artery should needs be. This approac h, via the
right femoral artery, is preferred by the authors
due to the left femoral artery often being used for
access during cardiac catheterization. This can
result in more difficult left-sided access as well as
scarring and hematoma. A 1 to 2 cm vertical skin
incision is made above the groin crease, overlying
the femoral vessels [9]. The inguinal ligament is
then retracted, the vessel exposed proximally on
the common femoral artery and a 5–0 Prolene
purse-string is then placed. The artery is cannulated through this suture using a Seldinger technique. Should higher flow rates be required, or
sufficient perfusion is limited due to the use of an
IntraClude endo-aortic balloon occlusion device
[10] (Edwards Lifesciences, Irvine, CA, USA), a
further arterial cannula can be placed in the contralateral femoral artery (Fig. 1).
Content
1 6F Pigtail (Impulse—Boston Scientific)
1 Amplatz Super Stiff J-Tip 260 cm (Boston
Scientific)
Terumo angled guide wire (1 blue & 1 brown)
260 cm (Radifocus)
Merit Medical J-Tip Inqwire guide wire 260 cm
1 Occlusion Balloon Catheter Berenstein (Boston
Scientific) + 2 three-way lock + 2 20 mL syringe
4 Perclose Proglide 6F (Abbott)
1 Angio-Seal 8F Vascular Closure Device
1 6F port
2.2 Axillary Cannulation
Axillary or subclavian arterial access should be
followed if significant peripheral vascular disease
has been identified, either preoperatively or at the
time of femoral cutdown. After a 3 cm skin
incision is made 1 cm beneath the clavicle,
medial to the deltopectoral groove, the pectoralis
muscles are separated or divided and localization
is made throu gh finger guidance of the axillary
arterial pulse (taking care not to cause injury or
excessive traction on the brachial plexus). Flexible vessel loops allow for proximal and distal
control of the vessel. The proximal aspect of the
artery is clamped with a vascular clamp and the
distal loop is retracted. Injury can ensue as the
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