Evolution of Femoral Cannulation Techniques in Minimally Invasive Mitral Valve Surgery: A 10-Year Experience

Q: What are the key findings of this study?

Ultrasound-guided percutaneous femoral cannulation yielded comparable groin complication rates to open cut-down (4.9% vs 2.8%, p=0.51) while eliminating lymph fistulas (0% vs 4.3%, p=0.0004).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Mitral valve disease undergoing minimally invasive mitral valve surgery (MIMVS) (n=575). Intervention: Ultrasound-guided percutaneous femoral cannulation with MANTA vascular closure vs. Open surgical femoral cut-down cannulation. Primary outcome: Occurrence of groin complications (composite of access site hematoma requiring intervention, pseudoaneurysm, arterial or venous thrombosis, limb ischemia, access site infection, seroma, or need for surgical/endovascular intervention) (p=0.51).

Q: What does this research mean for the field?

Ultrasound-guided percutaneous femoral cannulation achieves comparable groin complication rates to surgical cut-down while eliminating lymphatic fistulas and reducing operative times in minimally invasive mitral valve surgery. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Jonah Schwarz; Parwis Massoudy; Marius Mihai Harpa; Markus Czesla; Christian Mogilansky; Klara Brînzaniuc; Emanuel-David Anitei; Robert Balan

doi:10.3390/medsci14020182

April 3, 2026Medical SciencesOpen Access

Evolution of Femoral Cannulation Techniques in Minimally Invasive Mitral Valve Surgery: A 10-Year Experience

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Key result

Percutaneous femoral cannulation matches open cut-down for groin complications while eliminating lymph fistulas.

P=0.51
n=575

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Why the study?

The study evaluated how transitioning from open femoral cut-down to ultrasound-guided percutaneous cannulation affects procedural efficiency, vascular safety, and postoperative outcomes in minimally invasive mitral valve surgery.

Does ultrasound-guided percutaneous femoral cannulation with MANTA closure reduce groin complications and improve operative efficiency compared to open femoral cut-down in patients undergoing minimally invasive mitral valve surgery?

Key Points

To evaluate the impact of transitioning from open femoral cut-down to ultrasound-guided percutaneous cannulation on procedural efficiency, vascular safety, and postoperative outcomes in minimally invasive mitral valve surgery.
Retrospectively analyzed 575 consecutive patients undergoing minimally invasive mitral valve surgery between 2014 and 2025 at a single center.
Compared open femoral cut-down performed before 2021 (n=393) with ultrasound-guided percutaneous cannulation and MANTA closure performed from 2021 onward (n=182).
Conducted propensity score matching to generate 72 balanced pairs for adjusted operative and complication comparisons.
Percutaneous access was associated with significantly shorter cardiopulmonary bypass times (115 vs. 128 min, p < 0.0001), operative times (210 vs. 242 min, p < 0.0001), ICU stays (2 vs. 3 days, p = 0.0267), and hospital stays (8 vs. 11 days, p < 0.0001).
Lymph fistula occurred in 4.3% of cut-down cases and 0% of percutaneous cases (p = 0.0004), while overall groin complication rates did not differ significantly (2.8% vs. 4.9%, p = 0.51).
MANTA closure demonstrated a 2.2% device-related complication rate (1.1% bleeding and 1.1% limb ischemia), and 30-day mortality was 4.6% in the cut-down group versus 1.6% in the percutaneous group (p = 0.096).

Study Design

Type

Cohort (n=575)

Multicenter

No

Structured PICO

Does ultrasound-guided percutaneous femoral cannulation with MANTA closure reduce groin complications and improve operative efficiency compared to open femoral cut-down in patients undergoing minimally invasive mitral valve surgery?

P

Population

575 consecutive adults undergoing minimally invasive mitral valve surgery via right mini-thoracotomy at a single center in Germany (2014-2025), followed for up to 30 days postoperatively.

E

Exposure

Ultrasound-guided percutaneous femoral cannulation (performed from January 2021 onward, n=182) utilizing a 24 Fr Smart Venous Cannula or 23 Fr Bio-Medicus multistage venous cannula for venous drainage, 21–23 Fr ThruPort cannula for arterial access, and the MANTA vascular closure device for arterial decannulation along with a Z-suture and Safeguard compression device for venous decannulation.

C

Comparator

Open surgical femoral cut-down exposure (performed before January 2021, n=393) using Seldinger technique under direct vision through a small groin incision, secured with purse-string sutures (two for arterial, one for venous) and repaired by knotting the purse-string sutures after decannulation. Both groups underwent MIMVS through a right anterolateral mini-thoracotomy in the fourth intercostal space under moderate hypothermia (34 °C) with single-shot Bretschneider cardioplegia.

O

Outcome

Occurrence of groin complications (composite endpoint including access site hematoma requiring intervention, pseudoaneurysm, arterial or venous thrombosis, limb ischemia, access site infection, seroma, or the need for surgical or endovascular intervention).composite

Main Result

Absolute Event Rate: 4.9% vs 2.8%

p-value: p=0.51

Transitioning from open surgical cut-down to ultrasound-guided percutaneous femoral cannulation with MANTA closure in minimally invasive mitral valve surgery eliminated lymphatic fistulas and significantly reduced operative, cardiopulmonary bypass, ICU, and hospital stay durations without increasing groin vascular complications or 30-day mortality.

Limitations

Retrospective single-center design limiting external generalizability
Selection bias and period confounding as percutaneous cannulation was performed in the later era (2021 onward) alongside institutional maturation
Propensity score matching reduced the analyzable matched cohort to 72 pairs (144 patients), limiting statistical power for secondary endpoints
Incomplete mortality data for early study years and lack of long-term follow-up beyond 30 days
Secondary outcomes such as re-exploration for bleeding were analyzed descriptively without dedicated multivariable modeling
Selection bias and residual confounding related to period effects, as percutaneous cannulation was performed later in the study period alongside increasing institutional experience
Inability to reliably determine how many patients were excluded based on preoperative CT angiography findings
Substantial reduction of sample size in the propensity score matched cohort (72 matched pairs), potentially limiting statistical power for secondary endpoints
Incomplete mortality data for early study years and lack of long-term outcomes beyond 30 days

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Implication

Supports percutaneous femoral access in mitral valve surgery to eliminate lymph fistulas without added complications; leaves open randomized trials for efficiency gains.

Abstract

Background: Femoral cannulation is essential for minimally invasive mitral valve surgery (MIMVS). Our center transitioned from open femoral cut-down to ultrasound-guided percutaneous cannulation supported by smart venous cannulas, ThruPort arterial access, and the MANTA closure device. This study evaluates how this transition affects procedural efficiency, vascular safety, and postoperative outcomes. Methods: We retrospectively analyzed 575 consecutive MIMVS patients (2014–2025). Patients treated before 2021 formed the cut-down group, while those from 2021 onward underwent percutaneous cannulation. The outcomes included operative times, groin and lymphatic complications, MANTA performance, and 30-day mortality. Propensity score matching (PSM) was performed to adjust for baseline differences. Results: Of 575 patients, 393 (68.3%) underwent cut-down and 182 (31.7%) percutaneous access. Percutaneous access was associated with shorter cardiopulmonary bypass times (115 vs. 128 min, p < 0.0001), total operative times (210 vs. 242 min, p < 0.0001), ICU stays (2 vs. 3 days, p = 0.0267), and hospital stays (8 vs. 11 days, p < 0.0001). Lymph fistula occurred in 4.3% of cut-down cases and in 0% after the adoption of percutaneous access (p = 0.0004). Overall groin complication rates were comparable (2.8% vs. 4.9%, p = 0.51). MANTA closure had a 2.2% device-related complication rate (1.1% bleeding; 1.1% ischemia) with no documented long-term sequelae. Regarding 30-day mortality, this was 4.6% in the cut-down group and 1.6% in the percutaneous group (p = 0.096). In PSM (72 matched pairs), percutaneous access retained significantly shorter operative, bypass, and ICU times, with identical groin complication rates. Conclusions: Ultrasound-guided percutaneous femoral cannulation was associated with improved procedural efficiency and elimination of lymphatic morbidity, without increasing vascular risk or mortality. It represented a safe and effective standard strategy for contemporary MIMVS.

Discussion

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Cite This Study

Schwarz et al. (2026) conducted a cohort in Mitral valve disease undergoing minimally invasive mitral valve surgery (MIMVS) (n=575). Ultrasound-guided percutaneous femoral cannulation with MANTA vascular closure vs. Open surgical femoral cut-down cannulation was evaluated on Occurrence of groin complications (composite of access site hematoma requiring intervention, pseudoaneurysm, arterial or venous thrombosis, limb ischemia, access site infection, seroma, or need for surgical/endovascular intervention) (p=0.51). Ultrasound-guided percutaneous femoral cannulation yielded comparable groin complication rates to open cut-down (4.9% vs 2.8%, p=0.51) while eliminating lymph fistulas (0% vs 4.3%, p=0.0004).

synapsesocial.com/papers/69d49fe5b33cc4c35a228603 https://doi.org/10.3390/medsci14020182

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Evolution of Femoral Cannulation Techniques in Minimally Invasive Mitral Valve Surgery: A 10-Year Experience

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Evolution of Femoral Cannulation Techniques in Minimally Invasive Mitral Valve Surgery: A 10-Year Experience

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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