Risk factors for lower limb ischemia in minimally invasive and robotic-assisted cardiac valve surgery: a...

Lower limb ischemia is a critical complication of femoral cannulation during minimally invasive and robot-assisted cardiac surgery. We aimed to evaluate the validity of our intraoperative near-infrared spectroscopy (NIRS) monitoring strategy and identify risk factors for distal perfusion.

We retrospectively analyzed 329 patients who underwent minimally invasive or robotic-assisted cardiac surgery with ipsilateral femoral arteriovenous cannulation between 2014 and June 2025. The primary outcome was intraoperative Tissue oxygenation index (TOI) desaturation requiring distal perfusion, defined as a >10% decline from baseline in the cannulated limb. Femoral artery (FA) diameter and femoral vein (FV) cross-sectional area were measured on preoperative computed tomography (CT). Risk factors were assessed by logistic regression, and receiver operating characteristic (ROC) analysis determined optimal cut-off values.

Intraoperative TOI desaturation requiring distal perfusion occurred in 34 patients (10.3%). Multivariable analysis revealed that age (P=0.03) and FA-cannula diameter difference (P<0.001) were independent predictors. The optimal FA-cannula diameter difference cut-off was 1.7 mm. No postoperative limb complications occurred, and postoperative enzyme levels were not elevated in those requiring distal perfusion.

A smaller FA-cannula diameter difference and younger age independently predicted intraoperative lower limb ischemia. NIRS-guided distal perfusion may be a safe and effective strategy to prevent ischemic complications.