In minimally invasive cardiac surgery, femoral artery cannulation is widely used; however, it may cause lower-limb ischemia. We developed a standardized patient-selection strategy, a femoral artery–cannulation technique, and a structured ischemia-prevention protocol and evaluated their reproducibility and clinical effectiveness in preventing limb ischemia.

We retrospectively analyzed 505 patients who underwent totally endoscopic minimally invasive cardiac surgery with femoral artery cannulation between June 2019 and July 2024. The arterial cannula was inserted with the proximal side hole directed dorsally and secured at a shallow depth to facilitate distal perfusion. Regional oxygen saturation of both lower limbs was continuously monitored. A >50% decrease in regional oxygen saturation triggered a stepwise protocol: increased cardiopulmonary bypass flow, topical papaverine hydrochloride solution, and, if unresolved, distal perfusion via a 6-Fr sheath. The incidences of clinical limb ischemia (need for distal perfusion or compartment syndrome) and a >50% decrease in regional oxygen saturation were evaluated, and risk factors for regional oxygen saturation decrease were identified.

No patients required distal perfusion or developed postoperative compartment syndrome. A >50% decrease in regional oxygen saturation occurred in 28 patients (5.5%), all of whom recovered without distal perfusion. Multivariate analysis identified smaller femoral artery diameter and low ejection fraction as independent risk factors for regional oxygen saturation decrease.

A standardized patient-selection strategy combined with a femoral artery–cannulation technique and a structured ischemia-prevention protocol effectively prevented clinically significant limb ischemia without the need for distal perfusion in this cohort.