Introduction

One of the most frequently used incisions in cardiovascular surgery is the femoral artery incision after sternotomy or thoracotomy. There has always been a debate in deciding the type of incision regarding the operations in which the femoral artery preparation is necessary. Two types of incisions have been accepted for the regions of common and superficial femoral artery branching sites; longitudinal (parallel to femoral artery trace), oblique (parallel to inguinal ligament and two cm distally). Because the longitudinal incision provides a comfortable approach to the femoral artery segment, it has gained a widely accepted priority. But unfortunately, for the reason that it does not have the same orientation with the skin lining defined by Langhans, the wound healing direction is opposite. Lymphorrhage is a frequent complication, because the region is rich in lymphatics and during the dissection, lymphatic integrity breaks down. This may cause delay in wound healing, wound and graft infections.

Femoral artery is explored in peripheral by-pass operations, endovascular stent procedures and for femoral artery cannulations. For insertion of intra-aortic balloon pump (IABP), a percutaneous method of approach , Seldinger's method, is widely preferred. In this study, we evaluated the incidence of lymphorrhage, wound infections and early vascular complications in oblique and longitudinal surgical femoral incisions and intra-aortic balloon pump insertion techniques, percutaneous or surgical.

Materials And Methods

We classified the patients who have been operated in our center during last 10 year according to their surgical procedures such as IABP insertion and femoral surgical procedures (Table 1). We compared 440 IABP patients (group A) in their own group according to their insertion technique as percutaneous (group A1, n=322) and two surgical incision types (group A2-longitudinal incision, n=94 and group A3-oblique incision, n=24) (Table 2). In group B, we compared 343 patients underwent a peripheral bypass operation whose femoral arteries were used, according to incision type as longitudinal (group B1, n=298) and oblique (group B2, n=45) (Table 3). We evaluated the incidence of lymphorrhage, wound infections and early vascular complications.

Figure 1

Table 1: Study groups

Figure 2

Table 2: Postoperative values between Group B1 and Group B2

Figure 3

Table 3: Group A subgroup relations. Postoperative complication incidence P

Results

When surgical longitudinal and oblique incisions were compared, group B1 had significantly more wound infections than group B2 (p< 0.05). Group B1 had more lymphorrage than group B2, but this was statistically not significant (p= 0.1719). In Group A, wound infections were more likely to be seen in group A2 than in group A1 (p= 0.0041). No wound infection was seen in group A3. When three groups were compared for early vascular events, we noticed that group A1 had more vascular events, than group A2 and A3. (p=0.089 and 0,2696). No lymphorrage was seen in group A1 and it was more frequent in group A2 than group A3 (p=0.572). In statistical analysis univariant t test is used p<0.05 is considered statistically significant. The demographics of each gropus are given in Table 4.

Figure 4

Table 4. Demographic values. Group A and Group B age, gender, and preoperative risk factors which may influence post operative success. (n= number of patients, %= percentage of in its own group. Age values was calculated as ±SD (standard Deviation))

Discussion

Radiological studies carried out on the region of femoral artery for antegrad puncture, they showed that the femoral artery is placed on cranial for femoral bifurcation and caudal for inguinal ligament. ₁ Angiographic studies showed that the common femoral artery was small in diabetic, female and thin people. Femoral artery punctions was made in 13 percent in a vessel other than the femoral artery and in 54 percent of cases the puncture region was inappopriate anatomically. For this reason, routine fluoroscopic guide assistance is recommended in performing femoral puncture.2 In 14 percent of the cases with percutaneous IABP insertion, acute lower extremity ischaemia was observed and 71.4 percent out of these recovered after extraction of IABP. Embolectomy additionally after IABP extraction was carried out in 24 percent. An additional revascularization procedure was found out to be necessary in 30 percent of the cases which had no recovery after balloon extraction. Hemorrhage at the site of IABP insertion was observed in 5.1 percent of the cases, no recovery was observed after local compression and necessitated a surgical repair. Female gender, diabetes, peripheral arterial disease were found to be the risk factors in vascular IABP related vascular complications. ₃,₄ Deep femoral artery is a major collateral way especially in patients who have occlusive superficial femoral artery disease. ₅ In a study which compares the percutaneous and surgical balloon insertion methods,it was found out that there was significantly more vascular complicatons such as asymptomtic pulse deficiency, infection and balloon rupture. ₆ It was found that local arteriotomy closure devices has no benefit, local compression is the clasical method for the control of haemorrhage. ₇ In the endovascular stent insertion procedures the preffered method is the minimal invasive oblique femoral approach for femoral artery preperation. The oblique femoral incision is preferred to longitudinal. It was found out that cellulitis, subcutaneous purulance, graft infection and lymphatic fistulae were encountered in a lesser extent. ₈ In an other study it was shown that there was an oxygen saturation difference between the lateral and medial parts of the longitudinal incision. This finding can explain why incidence of infection is higher in longitudinal incision. ₉ When these two incisions compared in a point for the occurence of lymphatic drainage and post-operative leg edema, there was no significant difference found. The lymphatic obstruction is the determinant factor of the post-operative leg edema. ₁₀ There was no superiority for one incision to another, both of them provide sufficient and comfortable surgical exposure. ₁₁ Moreover, the oblique femoral incision can be modified to a longitudinal trace when there is a need to reach distal superficial femoral artery. In our cases, we observed that there was more lymphatic drainage and more infection in longitudinal approach. When we compared the percutaneous inserted IABP cases with the surgical insertion we observed much more vascular complication related to the insertion and exertion techniques in the percutenous IABP group. In the surgical insertion the oblique incision provided a comfortable way, less wound infection,less lymphatic problems and less technique related vascular complications.

Conclusion

We suggest that in especially diabetic and obese patients, for the reason that it provides better wound healing and less risk of infection, the oblique incision has a considerable superiority. In cases of IABP need in cardiac surgery, oblique surgical approach should be preferred less vascular event rate due to direct exposure versus blind percutaneous technique.

Correspondence to

Mehmet Yilmaz M.D. Ciftlik sok 7/13 34718 Acibadem Istanbul Turkey PBX: 902163259074 drmehmetyilmaz@gmail.com