Aggressive placement of distal limb perfusion catheter in venoarterial extracorporeal membrane oxygenation

Abstract

Objective: The aim of this study is to review the impacts of aggressive placement of a distal perfusion catheter on the outcomes in patients supported with venoarterial extracorporeal membrane oxygenation via femoral cannulation. Methods: Analysis was performed with 143 consecutive femoral venoarterial extracorporeal membrane oxygenation cannulation. Patients were divided into two groups: the early period (October 2010 to December 2012, N = 47) where placement of a distal perfusion catheter was attempted percutaneously but not surgically and the late period (January 2013 to November 2018, N = 96) in which placement of distal perfusion catheter was aggressively utilized both percutaneously and surgically. The modification of venoarterial extracorporeal membrane oxygenation cannulation protocol for the late period involved (1) an immediate insertion of a distal perfusion catheter regardless of the size of femoral arterial cannula, (2) an open insertion of a distal perfusion catheter if percutaneous approach failed, and (3) when venoarterial extracorporeal membrane oxygenation cannulation was completed at a non-extracorporeal membrane oxygenation cannulation center, it was encouraged that they attempt insertion of a distal perfusion catheter at the time of cannulation. Results: In the late period, a distal perfusion catheter was placed in 96% (92/96) which was significantly increased from 66% (31/47) in the early period. Of these 92 patients in late period, nine patients (9.8%) required open direct insertion of a distal perfusion catheter. The incidence of lower limb ischemia (early vs. late period 26% vs 12%, P = 0.031) was significantly decreased in the late period. Logistic regression analyses showed that distal perfusion catheter placement was the only factor for preventing lower limb ischemia. Conclusion: Aggressive insertion of a distal perfusion catheter even utilizing surgical cut-down technique was shown to decrease the incidence of distal limb complications.

Axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation support in cardiogenic shock

“…Often in acute cardiogenic shock, leg ischemia may result from low flow with less pulsatility; from vasoconstriction, due to high-dose vasopressor use; or from other mechanical support devices inserted via the FA, such as an intra-aortic balloon pump, or Impella left ventricular assist device (Abiomed, Danvers, Mass). 3 , 5 , 10 As in most procedures, surgical technique is important for successful AX cannulation. In the present study, although bleeding was the most common complication of AX cannulation (15%), the incidence had improved to 4.0% over the past 3 years (January 2017 to October 2019) with meticulous surgical technique and diligent management of pump speed.…”

“…Cannulation-related limb ischemia was defined as ischemia requiring any surgical procedure, including revision of the arterial/distal perfusion cannula, fasciotomy for compartment syndrome, gangrene, or amputation. 2 , 3 , 4 , 5 Cannulation-related wound complication was defined as infection or requirement of an additional surgical intervention, such as arterial repair, washout with or without vacuum-assisted closure, and muscle flap closure. Hyperperfusion was defined as a warm, hyperemic, edematous, or painful limb.…”

“…Despite its usefulness, potential concerns of FA cannulation are retrograde arterial flow from the lower body and cannulation-related complications such as leg ischemia, bleeding, and infection, occurring in up to 35% of patients or more, which significantly impacts outcomes of VA-ECMO. 2 , 3 , 4 , 5 In addition, groin access to establish FA cannulation might be limited in patients with severe peripheral vascular disease (PVD) or indwelled temporary mechanical circulatory devices, which is frequently seen in a growing number of challenging patients. 1 The axillary artery (AX) can be an alternative arterial cannulation site that offers several potential benefits during VA-ECMO support: it is generally less calcified or diseased than the femoral vessels; it is less susceptible to infection due to it being less contaminated compared with groin and the presence of pectoral muscles; and it mostly provides antegrade flow to the systemic body.…”

Bedside angiography of distal perfusion catheter for veno-arterial extracorporeal membrane oxygenation

“…2 Patients with pre-existing vascular disease, hypercoagulable disorders, or states of low flow, either systemically or to their extremities, such as with high dose vasopressors, are at increased risk for ILE complications. 5,6 While placement of the distal perfusion catheter prior to the insertion of the arterial cannula is preferred in percutaneous cannulation, there are several clinical scenarios that do not allow for this. In emergent cannulations or an ECPR setting, institution of systemic circulation takes priority.…”

“…2 Patients with pre-existing vascular disease, hypercoagulable disorders, or states of low flow, either systemically or to their extremities, such as with high dose vasopressors, are at increased risk for ILE complications. 5,6…”