Distal Perfusion Cannulation and Limb Complications in Venoarterial Extracorporeal Membrane Oxygenation

Abstract

The utility of distal perfusion cannula (DPC) placement for the prevention of limb complications in patients undergoing femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is poorly characterized. Patients undergoing femoral VA ECMO cannulation at two institutions were retrospectively assessed. Patients were grouped into those who did and those who did not receive a DPC at the time of primary cannulation. The primary outcome was any limb complication. Secondary outcomes included successfully weaning ECMO and in-hospital mortality. A total of 75 patients underwent femoral cannulation between December 2010 and December 2017. Of those, 65 patients (86.7%) had a DPC placed during primary cannulation and 10 patients (13.3%) did not. Baseline demographics, indications for ECMO, and hemodynamic perturbations were well matched between groups. The rate of limb complications was 14.7% (11/75) for the overall cohort and did not differ between groups (p = .6). Three patients (4%) required a four-compartment fasciotomy for compartment syndrome in the DPC group; no patients without a DPC required fasciotomy. Of the three patients who required a thrombectomy for distal ischemia, two were in the DPC group and one was in the no-DPC group (p = .3). Two patients (2.7%) underwent delayed DPC placement for limb ischemia with resolution of symptoms. The in-hospital morality rate was 59.5% and did not differ between groups (p = .5). Patients in the present study, undergoing femoral VA ECMO without preemptive DPC placement did not experience a higher rate of limb complications. However, the two patients who underwent delayed DPC placement for post-cannulation ischemia experienced resolution of symptoms, suggesting that a DPC may be used as an effective limb salvage intervention.

Preventing Acute Limb Ischemia during VA-ECMO—In Silico Analysis of Physical Parameters Associated with Lower Limb Perfusion

“…Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an extracorporeal circulatory support system for the heart and lungs. It is notably used for patients with refractory cardiogenic shock secondary to cardiac surgery, decompensated cardiomyopathy, acute myocardial infarction, or refractory cardiac arrest [ 1 ]. VA-ECMO can be used as a bridge to heart or lung transplantation and as a bridge to organ recuperation after such transplants.…”

“…During VA-ECMO, the patient’s deoxygenated blood is drained through a venous cannula, passed through an oxygenator, and reinjected through an arterial cannula. In adults, the cannulation is often done peripherally in the femoral vein and artery [ 1 ]. Current arterial cannulas allow good perfusion of the upper body and thus adequate circulatory support, but they can prevent blood flow from reaching the lower limb downstream of the cannula, which can lead to ipsilateral acute limb ischemia (ALI) [ 2 ].…”

Is Fasciotomy Associated With Increased Mortality in Extracorporeal Cardiopulmonary Resuscitation?

“…[5][6][7] Although the insertion of a DPC may preserve distal limb arterial perfusion, DPC may not be effective in treating all mechanisms of limb ischemia, such as acute compartment syndrome (ACS). 8,9 Acute compartment syndrome is a limb-threatening emergency and occurs due to increased compartmental pressure due to the noncompliant fascia that surrounds an extremity compartment. 1 In patients on ECMO, ACS can develop for a multitude of reasons, which include ischemia secondary to cannulation, direct bleeding into muscular compartments, or reperfusion injury.…”

“…5–7 Although the insertion of a DPC may preserve distal limb arterial perfusion, DPC may not be effective in treating all mechanisms of limb ischemia, such as acute compartment syndrome (ACS). 8,9…”