Cannulation‐related adverse events of peripheral veno‐arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation

Abstract

Background In heart transplantation (HT), peripheral veno‐arterial extracorporeal membranous oxygenation (VA‐ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA‐ECMO cannulation site which can be fatal. Methods From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA‐ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). Results Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA‐ECMO cannulation‐related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation‐related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram‐negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation‐related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation‐related complications. Conclusions Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA‐ECMO may be an excellent option in HT candidates or recipients when possible

Groin wound management after decannulation of veno‐arterial extracorporeal membrane oxygenation in heart transplantation: Role of sartorius muscle flap

“…Axillary VA-ECMO has been shown to reduce cannulation-related wound complications over FA cannulation. 2 Central cannulation provides reliable access but carries additional risks. 14 Avoidance of cutdown decannulation using percutaneous closure devices can potentially reduce ECMO-related groin complications, however may not be feasible in emergent cases.…”

“…FA cannulation was executed either percutaneously or surgically with a 15-or 17-French arterial cannula, and distal limb perfusion was routinely accomplished by inserting a 5 to 8-French wire-reinforced catheter into the superficial femoral artery (SFA). 2,11 The femoral vein was accessed percutaneously. Intravenous antibiotics was administered during VA-ECMO support as prophylaxis.…”

“…Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support continues to grow in patients with cardiogenic shock and can be utilized as either a bridge to transplant in profound cardiogenic shock or as support for primary graft dysfunction after heart transplantation (HT). 1,2 Femoral artery (FA) cannulation is the most common approach for VA-ECMO support as it is expeditious and many providers are familiar with this reliable access. However, femoral cannulations often require surgical cutdown for decannulation due to the arterial cannula size.…”

“…3,4 There are multiple factors which can affect wound healing after HT: use of immunosuppressive medications, steroid-induced diabetes mellitus, perioperative hemodynamics, and pre-transplant nutrient status. 2,5,6 Wound complications includes not only delayed healing but also local infection such as abscess formation or pseudoaneurysm of FA as well as remote infection such as endocarditis or mycotic aneurysms. 7 Wound complications after VA-ECMO decannulation poses a significant challenge due to the lack of reliable tissue such as muscle or fascia above the femoral vessels, difficulty of applying conservative wound management on groin such as regular dressing material or vacuum assisted closure (VAC) and the risk of infection due to proximity the perineum.…”

“…Wound complications after VA‐ECMO decannulation have been recognized as a serious and potentially fatal complication in thoracic transplant patients 3,4 . There are multiple factors which can affect wound healing after HT: use of immunosuppressive medications, steroid‐induced diabetes mellitus, perioperative hemodynamics, and pre‐transplant nutrient status 2,5,6 . Wound complications includes not only delayed healing but also local infection such as abscess formation or pseudoaneurysm of FA as well as remote infection such as endocarditis or mycotic aneurysms 7 .…”