To the Editor:—

We read with great interest the case report of Höhn et al. , 1which recommended arteriovenous femoral cannulation during local anesthesia before induction of general anesthesia in the case of severe pulmonary hypertension. We believe that this statement is judicious; however, we describe a case in which this procedure failed.

A 50-yr-old woman was scheduled to undergo double lung transplantation for severe pulmonary hypertension resulting from scleroderma. Transthoracic echocardiography showed a rapid increase in systolic pulmonary arterial pressure from June 1999 (80 mmHg) to September 1999 (126 mmHg). In October, her clinical condition worsened further: dyspnea was significant, movement to the supine position was impossible, and attempts were associated with faintness. Inhaled nitric oxide slightly improved the clinical status of the patient, although it was ineffective in decreasing pulmonary arterial pressure. Emergency lung transplantation was performed. We decided to perform cardiac cannulation via  the femoral artery and vein with use of a local anesthetic before induction of anesthesia. The femoral vessels were surgically exposed, with the patient in the sitting position during local anesthesia. The sitting position did not allow complete insertion of the cannulas. Attempting to move the patient to the semisitting position was impossible because of the refusal of the patient, who was experiencing distress as a result of respiratory failure. We had to use general anesthesia (including intravenous sufentanil, etomidate, and rocuronium bromide) with the patient in the sitting position. Circulatory failure and cardiac arrest occurred immediately after induction of anesthesia. Tracheal intubation and external cardiac massage were immediately performed. Then, complete insertion of the cannulas was achieved, anesthesia was achieved, and cardiopulmonary bypass was begun. Double lung transplantation was performed uneventfully. Then, the patient was discharged from the hospital.

In conclusion, we agree with Höhn et al.  1about the use of the femoral route during local anesthesia for the cannulation of the patient undergoing lung transplantation in whom a significant increase in pulmonary arterial pressure was seen. However, extreme and unusual clinical situations exist in which this procedure could fail.

Hohn L, Schweizer A, Morel DR, Spiliopoulos A, Licker M: Circulatory failure after anesthesia induction in a patient with severe primary pulmonary hypertension. A nesthesiology 1999; 91: 1943–5