Abstract
Objective
Acute limb ischemia (ALI) and cannulation site bleeding are frequent complications
of venoarterial (VA) extracorporeal membrane oxygenation (ECMO) and are associated
with worse outcomes. The goals of this study were to assess our rates of ECMO-related
ALI and bleeding and to evaluate the efficacy of strategies to prevent them, such
as distal perfusion cannula (DPC) and ultrasound-guided cannulation.
Methods
This is a single-center retrospective cohort study of adult patients placed on peripheral
VA-ECMO at a tertiary medical center between 2014 and 2018. ALI was defined as new
ischemia of the extremity ipsilateral to arterial cannulation. Significant cannulation
site bleeding was defined as excessive bleeding requiring intervention (eg, transfusion
or reoperation). Univariate analyses were used to identify factors associated with
ALI, bleeding, and in-hospital mortality.
Results
During the study period, 105 patients were placed on peripheral VA-ECMO (61.3% female;
mean age, 54.9 ± 14.8 years). Nearly half (46.6%) had ECMO implantation in an extracorporeal
cardiopulmonary resuscitation setting and 37 (44.0%) had a DPC. Average duration of
support was 5.6 ± 5.0 days. Overall in-hospital mortality and death on ECMO support
were 65.1% and 50%, respectively. ALI occurred in 21 (20%) and cannulation-related
bleeding occurred in 24 (22.9%) patients who were treated with a total of 27 procedures,
including thromboembolectomy (22.2%), vascular repair (18.5%), and fasciotomy (25.9%).
On univariate analysis, cannulation in the operating room (odds ratio [OR], 0.25;
95% confidence interval [CI], 0.08-0.77; P = .02) was associated with decreased risk of ALI, whereas cannulation in the operating
room (OR, 2.65; 95% CI, 1.09-6.45; P = .03) and cutdown approach (OR, 4.96; 95% CI, 2.32-10.61; P < .0001) were associated with increased risk of bleeding. Ultrasound-guided placement
was associated with decreased risk of bleeding (OR, 0.81; 95% CI, 0.04-0.84; P = .03). DPC was not associated with either ALI (P = .47) or bleeding (P = .06). ALI (OR, 2.68; 95% CI 1.03-6.98; P = .04), age (OR, 1.94; 95% CI, 1.03-3.69; P = .04), and worse baseline heart failure (OR, 2.01; 95% CI, 1.02-3.97; P = .04) were associated with greater risk of in-hospital mortality. Ultrasound-guided
cannulation (OR, 0.41; 95% CI, 0.20-0.87; P = .02) was associated with decreased risk of in-hospital mortality.
Conclusions
ALI and significant bleeding are common occurrences after peripheral VA-ECMO cannulation.
Whereas DPC placement did not significantly decrease risk of ALI, ultrasound-guided
cannulation decreased the risk of bleeding. Cannulation in the operating room is associated
with decreased risk of ALI at the expense of increased risk of bleeding. ALI, older
age (≥65 years), and worse heart failure increased risk of in-hospital mortality.
Keywords
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Article Info
Publication History
Published online: July 02, 2020
Accepted:
May 24,
2020
Received:
January 14,
2020
From the Society for Vascular SurgeryFootnotes
L.N.K. was supported by the Joseph B. & Marjorie M. Lanterman Endowed Research and Education Fund (Northwestern University, United States). The funding entity was not involved in the decision to submit the manuscript for publication.
Author conflict of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
Identification
Copyright
© 2020 by the Society for Vascular Surgery. Published by Elsevier Inc.
