Modified T-Graft for Extracorporeal Membrane Oxygenation in a Patient with Small-Caliber Femoral Arteries

Abstract

Extracorporeal membrane oxygenation (ECMO) is generally used as a last resort toE xtracorporeal membrane oxygenation (ECMO) is a short-term mechanical circulatory support system for patients who are in advanced cardiac, pulmonary, or combined cardiopulmonary failure. Patients in cardiac failure are typically placed on venoarterial ECMO, and patients in respiratory failure are placed on venovenous ECMO. Large-diameter cannulas are needed to maintain high blood flow through the mechanical circulatory support system. However, upon insertion into blood vessels, these cannulas can reduce native blood flow, especially when vessel diameters are small. Acute limb ischemia can necessitate vascular reconstruction or amputation of the patient's extremities. We describe a modified T-graft technique that we used in order to avoid acute limb ischemia from ECMO in a young woman whose femoral arteries (FAs) were small. Case ReportIn April 2012, an 18-year-old woman presented with viral cardiomyopathy, systolic heart failure, and acute respiratory distress syndrome. She was intubated and was started on full mechanical ventilation. However, her pulmonary status continued to deteriorate, so we emergently placed her on ECMO. A 15F cannula was inserted in her right common FA, and a 19F cannula was inserted in her right common femoral vein. Several attempts to percutaneously place an antegrade distal-perfusion catheter in the right superficial FA failed because of small vessel size (diameter, 3-4 mm) and vasoconstriction. Critical limb ischemia subsequently developed in the patient's right leg. She remained hemodynamically unstable and would not have been able to tolerate a limb-revascularization procedure. During the next few days, her hemodynamic status improved; however, she became increasingly acidotic and sustained rhabdomyolysis and renal failure as the limb ischemia progressed. To prevent progression of the renal failure secondary to rhabdomyolysis, an emergency guillotine amputation of her right leg was performed, above the knee. At the same time, we decided to switch the ECMO to left femoral access by means of a modified T-graft technique, to avoid critical limb ischemia of her left leg.

The Effect of Acute Limb Ischemia on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation

“…23 The use of chimney and modified T-grafts has also been reported to avoid potential arterial complications. 24,25 The goal of our study was to clarify the effect of ischemic vascular complications on the mortality of VA ECMO. We were able to identify a strong association between ischemic vascular complications and mortality, which supports aggressive attempts to prevent these complications.…”

Efficacy of Distal Perfusion Cannulae in Preventing Limb Ischemia During Extracorporeal Membrane Oxygenation: A Systematic Review and Meta‐Analysis

“…Nonetheless, several operative techniques have been devised to improve distal arterial flow and potentially reduce limb ischemia . The two most commonly practiced techniques are (i) the use of distal perfusion cannulae (DPC) in a site distal to femoral cannulation , and (ii) performance of a T‐graft anastomosis in lieu of direct arterial cannulation .…”

High rate of arterial complications in patients supported with extracorporeal life support for drug intoxication-induced refractory cardiogenic shock or cardiac arrest

“…This attitude is shared by other teams involved in ECLS programs (28,30). There are other techniques for the prevention of lower limb ischemia which do not seem indicated in the routine daily practice [ligation of the posterior tibial artery and reperfusion of the distal extremity with a retrograde catheter (34), use of the dorsalis pedis artery for reperfusion of the leg (35)] or in urgent/ emergent situations [arterial cannula inserted into a Dacron graft anastomosed to the common femoral artery (36)]. Finally the subclavian/axillary artery is an elegant solution in order to reduce the risk of lower limb ischemia (37).…”