Complete percutaneous angio-guided approach using preclosing for venoarterial extracorporeal membrane oxygenation implantation and explantation in patients with refractory cardiogenic shock or cardiac arrest

Abstract

Background The approach for veno-arterial extracorporeal membrane oxygenation implantation (VA-ECMO) in patients with cardiogenic shock can be either surgical or percutaneous. Complete angio-guided percutaneous implantation and explantation could decrease vascular complications. We sought to describe the initial results of complete percutaneous angio-guided ECMO implantation and explantation using preclosing. Methods All consecutive patients who underwent peripheral femoro-femoral VA-ECMO percutaneous implantation for refractory cardiogenic shock or cardiac arrest were enrolled in a prospective registry (03/2018–12/2020). Percutaneous preclosing using two closing devices (Perclose ProGlide, Abbott) inserted before cannulation was used in both femoral artery and vein. Explantation was performed using a crossover technique under angiographic guidance. The occurrence of vascular complication was recorded. Results Among the 56 patients who underwent percutaneous VA-ECMO implantation for cardiogenic shock or refractory cardiac arrest, 41 underwent preclosing. Femoral vessel cannulation was successful in all patients and total cannulation time was 20 (10–40) min. Weaning from ECMO was possible in 22/41 patients (54%) and 12 (29%) patients were alive at day 30. Significant vascular complications occurred in 2/41 patients. Percutaneous decannulation was performed in 20 patients with 19/20 technical success rate. All femoral arteries and veins were properly closed using the pre-closing devices without bleeding on the angiographic control except for one patient in whom surgical closure of the artery was required. No patient required transfusion for access related significant bleeding and no other vascular complication occurred. Furthermore, no groin infection was observed after full percutaneous implantation and removal of ECMO. Conclusion Emergent complete percutaneous angio-guided VA-ECMO implantation and explantation using pre-closing technique can be an attractive strategy in patients referred for refractory cardiogenic shock.

Manual Compression versus Suture-Mediated Closure Device Technique for VA-ECMO Decannulation

“…A first pioneering study has indicated that removal of VA-ECMO cannulas with manual compression might be superior to surgical removal with respect to local infections, ischemia, and even survival [ 3 ]. Several successive case series have demonstrated that decannulation could even be improved if closure devices like Perclose ProGlide (Abbott Vascular, USA) or MANTA (Teleflex, USA) were applied [ 4 , 6 , 7 ].…”

Percutaneous decannulation of venoarterial extracorporeal membrane oxygenation using the Manta vascular closure device: A systematic review and meta‐analysis

“…4 Hence, operators must be aware of possible bail-out strategies such as tamponade with an endovascular balloon, covered stent implantation, or open surgical repair. 24 Shah et al routinely obtained contralateral common femoral artery access during VA-ECMO decannulation with the Manta VCD, which could facilitate rapid endovascular intervention if the Manta VCD fails or a vascular complication occurs. 16 Their case series reported a case where suction embolectomy was performed via a contralateral common femoral artery access in a patient who developed acute lower limb ischaemia after VA-ECMO decannulation with the Manta VCD.…”

Commentary: To slipknot or skip the knot: Preclosure in percutaneous extracorporeal membrane oxygenation cannulation, a misuse of precious time?

“…Low rates of cannulation site infections have also been shown using other percutaneous closure techniques following ECMO decannulation. [3][4][5][6][7] This would suggest that patients predisposed to a greater risk of groin infection (eg, smokers, those with diabetes or obesity) Peripheral percutaneous VA-ECMO decannulation is feasible, has a high success rate, and seems to reduce the number of groin infections.…”

“…The novelty of this report is that it represents the largest study in which a preclosure technique was used during urgent femoral VA-ECMO cannulation. Earlier this year, Martin-Tuffreau and colleagues 3 reported their experience with preclosing for urgent VA-ECMO using the double-ProGlide technique in an observational prospective study extending from 2018 to 2020. However, their cohort consisted of only 20 patients, and decannulation was performed using a crossover technique under angiographic guidance, which requires a hybrid operating room.…”

“…Low rates of cannulation site infections have also been shown using other percutaneous closure techniques following ECMO decannulation. 3 , 4 , 5 , 6 , 7 This would suggest that patients predisposed to a greater risk of groin infection (eg, smokers, those with diabetes or obesity) could benefit from a totally percutaneous VA-ECMO management strategy. Nevertheless, this may be modulated by the additional technical challenges related to the deployment of preclosure systems in the patient with obesity.…”