Authors: Tsujimoto H et al.
A & A Practice 19(11):e02076, November 2025
Summary
This case report describes two patients who developed false lumen perfusion following femoral artery cannulation for cardiopulmonary bypass, despite apparent confirmation of true lumen guidewire placement on transesophageal echocardiography. False lumen perfusion is a rare but catastrophic complication that can lead to severe organ malperfusion and collapse if not recognized immediately.
In the first case, a patient with acute Stanford type A aortic dissection underwent femoral artery cannulation with guidewire visualization in the true lumen on TEE prior to bypass initiation. Immediately after starting CPB, TEE revealed compression of the true lumen in the descending aorta accompanied by a sudden drop in distal arterial pressure. Rapid recognition of malperfusion led to immediate conversion to ascending aortic perfusion, restoration of true lumen flow, and an uncomplicated neurologic outcome.
The second case involved a patient without preexisting aortic disease who developed an iatrogenic retrograde dissection shortly after initiation of CPB via femoral cannulation. Despite TEE confirmation of guidewire position, abrupt hemodynamic changes and loss of arterial pressure signaled malperfusion. Repeat TEE demonstrated expansion of a false lumen extending from the descending to the ascending aorta. Prompt surgical intervention including hemiarch replacement and iliac artery stenting resulted in a favorable outcome.
These cases highlight that visualization of a guidewire within the aorta by TEE alone does not reliably exclude false lumen cannulation. Complex guidewire trajectories, re-entry tears, or micro-intimal injury can result in preferential false lumen pressurization once bypass flow begins. Continuous multipoint arterial pressure monitoring enabled early detection of malperfusion and allowed rapid changes in perfusion strategy before irreversible ischemic injury occurred.
The authors emphasize that combining TEE with simultaneous pressure monitoring at multiple arterial sites provides a more robust safety net during femoral cannulation. Antegrade perfusion strategies, such as axillary or ascending aortic cannulation, may reduce the risk of false lumen perfusion and should be considered, particularly in patients with known or suspected aortic pathology.
Key Points
False lumen perfusion can occur despite apparent true lumen guidewire placement on TEE
TEE alone is insufficient to guarantee safe femoral artery cannulation
Multipoint arterial pressure monitoring enables rapid detection of malperfusion
Immediate conversion to an alternative perfusion route can be life-saving
High vigilance is required at CPB initiation, when pressure gradients change abruptly
Thank you to A & A Practice for allowing us to summarize and discuss this clinically important case highlighting critical intraoperative decision-making in cardiac anesthesia.