Central Versus Peripheral Arterial Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Post-Cardiotomy Patients

Abstract

Different arterial cannulation strategies are feasible for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in postcardiotomy shock. We aimed to analyze potential benefits and safety of different arterial cannulation strategies. We identified 158 patients with postcardiotomy cardiogenic shock requiring VA-ECMO between 01/10 and 01/19. Eighty-eight patients were cannulated via axillary or femoral artery (group P), and 70 centrally via the ascending aorta directly or through an 8 mm vascular graft anastomosed to the ascending aorta (group C). Demographics and operative parameters were similar. Change of cannulation site for Harlequin’s syndrome or hyperperfusion of an extremity occurred in 13 patients in group P but never in group C (p = 0.001). Surgical revision of cannulation site was also encountered more often in group P than C. The need for left ventricular (LV) unloading was similar between groups, whereas surgical venting was more often implemented in group C (11.4% vs. 2.3, p = 0.023). Stroke rates, renal failure, and peripheral ischemia were similar. Weaning rate from ECMO (52.9% vs. 52.3%, p = NS) was similar. The 30 day mortality was higher in group P (60% vs. 76.1%, p = 0.029). Central cannulation for VA-ECMO provides antegrade flow without Harlequin’s syndrome, changes of arterial cannula site, and better 30 day survival. Complication rates regarding need for reexploration and transfusion requirements were similar.

Postcardiotomy shock extracorporeal membrane oxygenation: Peripheral or central?

“…The reports that support a benefit to central cannulation have low sample sizes. 8 , 11 The studies that show improved outcomes with peripheral cannulation include more patients, and include a meta-analysis, but are still retrospective. 9 , 12 , 13 Mariscalco and colleagues 9 published the largest study (apart from meta-analyses) and showed that peripherally cannulated patients had a lower in-hospital mortality.…”

“…The direct cannulation of the ascending aorta allows antegrade flow and avoids concerns with dual circulation (also known as North-South or Harlequin syndrome). 8 , 9 Dual circulation is a phenomenon in which inadequately oxygenated blood from the heart rather than oxygenated blood from the ECMO circuit feeds the head vessels. 10 Another advantage to central cannulation is that if the chest is already open in the operating room central cannulation might be faster than peripheral cannulation.…”

“…Two studies published in 2020 favor central cannulation. Radakovic and colleagues 8 reviewed 158 patients who required ECMO for PCS at their center between 2010 and 2019 and reported that 30-day survival was higher for centrally cannulated patients compared with those who were peripherally cannulated. They also reported that the peripherally cannulated group was more likely to require surgical cannulation revision because of either limb hyperperfusion or dual circulation.…”

Echocardiography for extracorporeal membrane oxygenation

“…Arterial cannulation can be performed peripherally via femoral or axillary cannulation or centrally via cannulation of the ascending aorta. 37 Visualization of the arterial guidewire within either the descending thoracic aorta or ascending aorta serves as additional confirmation of correct arterial vascular access. This may be especially helpful in cases of profoundly impaired cardiac output and/or oxygenation where identification of the femoral artery can be challenging, especially in the emergent setting.…”

Algorithmic management of postcardiotomy shock with mechanical support: Bring a map, a plan, and your parachute—and know how to use all three

“…No consistent data have favored central over peripheral over peripheral strategies. 15,16 Multiple permutations of ECMO cannulation techniques are possible and should be adapted to patients' unique physiology and anatomy. 17 The Impella (Abiomed) is a temporary, percutaneous, transaortic LVAD.…”