Routine Use of Distal Arterial Perfusion in Pediatric Femoral Venoarterial Extracorporeal Membrane Oxygenation

Abstract

Lower-extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single-center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty-nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.

Comparing Percutaneous to Open Access for Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure

“…These results should be interpreted with caution as data on vessel patency following decannulation was not available from the registry. Early experiences with techniques for managing distal limb ischemia, such as the insertion of distal perfusion catheters with PERC or OPEN access in pediatrics, demonstrate feasibility but have not demonstrated definitive improvement in clinical outcomes (25, 26). More granular data, as may be obtained through multicenter retrospective reviews outside of registry data, is needed for detailed analyses of the use of distal perfusion techniques and more importantly, for evaluation of vessel patency and usability following decannulation (27, 28).…”

Pediatric and neonatal extracorporeal life support: current state and continuing evolution

“…One approach is to insert a distal perfusion catheter into the superficial femoral artery just distal to the cannulation site for anterograde flow [ 88 – 90 ] or into the posterior tibial artery for retrograde flow [ 91 ]. Data are limited and inconclusive on the relative benefit of prophylactic versus reactive placement of a distal arterial perfusion catheter in the pediatric population [ 92 ]. A distal venous drainage catheter has also been described as a method to decrease tissue edema and further improve perfusion during long-term ECLS [ 88 ].…”

“…A distal venous drainage catheter has also been described as a method to decrease tissue edema and further improve perfusion during long-term ECLS [ 88 ]. Close monitoring of limb perfusion in any patient with femoral cannulation is critical, regardless of the presence of a distal perfusion catheter, as limb ischemia can occur even after catheter placement [ 92 , 93 ]. Alternatively, rather than inserting a distal catheter, a prosthetic graft can be sewn to the femoral artery and subsequently cannulated (“stovepipe” or “side-arm” cannulation) to prevent occlusion of the native vessel with the cannula [ 94 ].…”

Artificial Organs 2017: A Year in Review

“…Schad et al of the Columbia University Medical Center, New York, NY, USA reported on a single‐center, retrospective review of 29 pediatric patients supported with femoral venoarterial extracorporeal membrane oxygenation (VA ECMO) comparing the outcomes of patients with prophylactic distal perfusion catheter (DPC) placement at cannulation (prophylactic DPC) to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complications requiring invasive intervention developed in 2 of 17 prophylactic DPC patients vs. 4 of 14 reactive DPC.…”