Femoral cannulation before redo sternotomy may offer a way to decompress the heart and prepare for difficult re-entry. A 2026 single-center retrospective study by Yu and colleagues reported lower red-cell transfusion requirements and fewer major cardiovascular injuries with this approach than with conventional central cannulation. However, substantial reporting inconsistencies limit the strength of that conclusion.
Why Femoral Cannulation Timing Matters in Reoperative Surgery
Repeat cardiac surgery presents a different access problem from a first operation. Adhesions can place the right ventricle, great vessels, or patent bypass grafts close to the posterior sternum. Opening the chest and separating those structures may therefore expose the team to bleeding before conventional central cannulation is available.
The study examines femoral arterial and venous cannulation before sternotomy, allowing bypass support and cardiac decompression during re-entry. The comparison strategy establishes central access after opening the sternum and dissecting the mediastinum. The clinical question concerns the combined strategy of access site, timing, and associated perfusion management—not simply one cannula position.
Who Was Studied?
The investigators reviewed operations performed between January 2022 and December 2024 at Nanjing First Hospital. Eligibility required adulthood, exactly one previous cardiac operation through a median sternotomy, an indication for reoperation, and complete records. Emergency surgery and patients with multiple previous sternotomies were excluded according to the stated criteria.
The publication describes 106 patients, but repeatedly gives group sizes of 79 for femoral cannulation and 37 for central cannulation. Those numbers total 116. The tables use the same group denominators, leaving the actual overall sample size unresolved. This review preserves the reported group figures while flagging the discrepancy.
Access was selected by the attending surgeon using imaging, peripheral vascular history, vessel size, and experience. Patients with unfavorable iliofemoral anatomy were preferentially assigned to central cannulation. This creates an important potential source of selection bias: the groups were not randomized, and access suitability itself may relate to outcomes.
What the Intraoperative Results Showed
| Reported measurement | Femoral group | Central group |
|---|---|---|
| Red-cell use | 2.1 ± 1.5 units | 3.5 ± 2.0 units |
| Intraoperative hemoglobin | 105.4 ± 12.8 g/L | 98.2 ± 14.1 g/L |
| Ultrafiltration volume | 1,850 ± 450 mL | 1,550 ± 420 mL |
| Mean central venous pressure | 6.5 ± 2.3 mmHg | 8.8 ± 2.5 mmHg |
The reported difference in average red-cell use was 1.4 units. This is an unadjusted between-group difference, not proof that femoral access independently saves that amount of blood. Transfusion exposure can also reflect bleeding, hemodilution, ultrafiltration, drainage performance, and clinical decisions.
Bypass time, cross-clamp time, total operative time, mean arterial pressure, lactate, and urine output were not statistically different in the reported comparisons. The abstract broadly states that intraoperative parameters did not differ, but Table 2 identifies several significant differences. Readers should therefore examine the individual outcomes rather than rely on that broad statement.
Cardiovascular Complications and Recovery
The authors report fewer major cardiovascular injuries in the femoral group. Their defined composite includes myocardial infarction, tamponade requiring drainage, new heart failure requiring support, significant arrhythmia, and major vascular complications. It should not be interpreted solely as accidental laceration during sternal re-entry.
No statistically significant differences were reported for perioperative mortality or ECMO use. Similarly, the publication did not demonstrate significant differences in acute kidney injury, cognitive dysfunction, stroke, ventilation time, ICU stay, or hospital stay. The absence of statistical significance in this small observational study does not establish equivalence between strategies.
Reported vascular access complications occurred in 10 of 79 femoral patients (12.7%) and 5 of 37 central patients (13.5%; p = 0.899). Two femoral patients developed limb ischemia. These data do not eliminate the potential for access-related injury or establish equal safety, particularly when uncommon complications are difficult to assess reliably in small groups.
What the Findings Mean for Perfusion Teams
The physiologic rationale is clinically relevant: bypass established before chest entry can reduce cardiac filling and provide circulatory support if dissection becomes difficult. The study also used vacuum-assisted venous drainage in the femoral approach. Better venous return and greater ultrafiltration are plausible contributors to the observed hemoglobin and transfusion differences, but the analysis does not isolate their effects.
For educational discussion, the paper highlights the connection between preoperative vascular assessment, the sequence of surgical access, venous drainage, and blood management. It does not establish a universal cannulation rule, a transfusion trigger, or a validated management protocol. Peripheral arterial disease, retrograde perfusion, embolic risk, and limb perfusion remain part of the access decision described by the authors.
For related IPA coverage, see redo mitral surgery through minithoracotomy. That report addresses a different surgical approach and should not be treated as direct confirmation of this comparison.
Important Reporting Limitations
Beyond the unresolved sample size, follow-up is described inconsistently: the Results refer to five-year survival, the figure caption refers to one-year survival, and the Discussion mentions two-year survival. The stated enrollment window and publication timing also make complete five-year follow-up implausible. A reliable time-specific survival conclusion cannot be drawn from those descriptions.
The Methods describe multivariable regression, while the limitations also mention propensity score matching. Clearly presented adjusted outcome estimates and a matched-cohort analysis are not supplied in the reported results. Consequently, the findings should not be represented as a robustly adjusted estimate of the independent effect of cannulation strategy. The text also discusses emergency access selection despite listing emergency surgery as an exclusion.
These concerns compound the usual limitations of a single-center, retrospective, nonrandomized comparison. They do not establish that the clinical hypothesis is wrong, but they reduce confidence in the numerical precision and in claims of improved safety. Prospective studies with consistent denominators, explicit outcome definitions, and transparent adjusted analyses are needed.
Original Article
Yu YH, Zhang XL, Wang L, Xiao LQ, Huang FH, Wang ZH. Exploring the application value of preoperative femoral artery and vein cannulation in redo cardiac surgery. Journal of Cardiothoracic Surgery. 2026;21:835. doi:10.1186/s13019-026-04262-y.
This independently written IPA educational review summarizes the uploaded publication. The original article is distributed under a Creative Commons Attribution–NonCommercial–NoDerivatives 4.0 license; the linked PDF remains unchanged. The cover is an AI-generated editorial illustration.
