IP153. Patients Undergoing Fasciotomy in the Setting of Extracorporeal Membrane Oxygenation Have a High Rate of Amputation With Poor Overall Survival and Functional Status

Abstract

Acute limb ischemia (ALI) and bleeding complications after venoarterial (VA) extracorporeal membrane oxygenation (ECMO) are frequent and are associated with worse outcomes. We sought to describe the rates and modifiable risk factors of ECMO-related vascular complications and to evaluate strategies believed to reduce those complications, such as distal perfusion catheters (DPC) and ultrasound-guided cannulation.Methods: This is a retrospective cohort study of adult patients placed on ECMO at a tertiary medical center between 2014 and 2018. Patient and periprocedural variables were collected from the electronic medical record. ECMO-related ALI was defined as ischemia of the extremity ipsilateral to the arterial cannulation site. Significant cannulation site bleeding was defined as excessive bleeding that required an intervention (eg, transfusion or reoperation). Univariate analyses were used to identify factors associated with ECMO-related ALI, bleeding, and in-hospital mortality.Results: Two hundred twenty-three consecutive patients were placed on ECMO during the study period. Most patients (144/223; 64%) underwent VA cannulation, of whom 40.5% were for extracorporeal cardiopulmonary resuscitation. The majority of patients (142/ 208; 68.3%) were percutaneously cannulated, and ultrasound examination was used during cannulation in 42 of 126 patients (33.3%) of. DPC were placed in 38 of 94 VA-ECMO patients (40.4%). Average duration of ECMO support and ICU stay were 7.4 days (standard deviation [SD], 10.9 days) and 21.0 days (SD, 25.9 days), respectively. ECMO-related ALI occurred in 26 of 211 (12.3%) and significant bleeding in 34 of 211 (16.1%) patients. Overall in-hospital mortality was 59.6% and death while on ECMO was 47.1%. Most patients with ALI (21/26; 80.8%) or significant bleeding (30/34; 88.2%) had VA cannulation. While DPC and ultrasound examination use were not associated with ALI, there were more bleeding complications when ultrasound was not used (17% vs 0%; P < .01). Being transferred from an outside hospital while on or for ECMO cannulation was also associated with a higher rate of ALI (20.4% vs 5.9%; P < .01). ALI was associated with in-hospital mortality (P < .05), but bleeding was not (P ¼ .71). extracorporeal cardiopulmonary resuscitation was not associated with higher rates of ALI or bleeding.Conclusions: ALI and bleeding are frequent complications of VA-ECMO cannulation. ALI is associated with worsened mortality. Future efforts at reducing ALI should focus on identifying factors surrounding intrahospital transfer. The use of ultrasound examination at the time cannulation may reduce rates of bleeding complications but does not seem to decrease rates of ALI. While DPC have been shown to prevent ALI, our population did not experience a significant benefit.

Is Fasciotomy Associated With Increased Mortality in Extracorporeal Cardiopulmonary Resuscitation?

“…This difference may potentially be due to higher mortality in the nonfasciotomy group (71% vs. 68%, p = 0.679), as patients generally require a better prognosis to undergo amputation, which may result in far greater blood loss than fasciotomy. 28,29,40 Nevertheless, our results differ sharply from that reported by Robins et al 16 in an abstract presented at the 2019 Vascular Annual Meeting. In their single-center retrospective study, only two patients of 23 (9%) had amputation-free survival.…”

“…28,29,40 Nevertheless, our results differ sharply from that reported by Robins et al . 16 in an abstract presented at the 2019 Vascular Annual Meeting. In their single-center retrospective study, only two patients of 23 (9%) had amputation-free survival.…”

“…15 Therefore, the net effect of fasciotomy on mortality in ECMO is unclear. Furthermore, the relatively low limb salvage rate after fasciotomy on ECMO 16 suggests that fasciotomy may not necessarily address the initial cause of limb ischemia in many cases, such as flow interruption due to cannulation.…”