Limb Ischemia Complications of Veno-Arterial Extracorporeal Membrane Oxygenation

Abstract

BackgroundThis study aimed to summarize and analyse the risk factors, clinical features, as well as prevention and treatment of limb ischemia complications in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO).MethodsWe retrospectively analyzed 179 adult patients who had undergone V-A ECMO support in the Cardiac Care Unit of the First Hospital of Lanzhou University between March 2019 and December 2021. Patients were divided into the limb ischemia group (LI group) and the non-limb ischemia group (nLI group) according to whether limb ischemia occurred on the ipsilateral side of femoral artery cannulation. In the LI group, patients were salvaged with a distal perfusion cannula (DPC) according to each patient's clinical conditions. The baseline data and ECMO data were compared between the two groups, and risk factors for limb ischemia complications were screened using multiple logistic regression analysis.ResultsOverall, 19 patients (10.6%) had limb ischemia complications, of which 5 (2.8%) were improved after medication adjustment, 12 (8.4%) were salvaged with a DPC, and 2 had undergone surgical intervention. There were significant differences in terms of Extracorporeal Cardiopulmonary Resuscitation (ECPR), Intra-aortic balloon pump (IABP), peak vasoactive-inotropic score (VIS) within 24 h after ECMO (VIS-max), Left ventricular ejection fraction (LVEF), weaning from ECMO, and discharge rate between the two groups. ECPR, IABP, and VIS-max in the LI group were significantly higher than those in the nLI group, whereas weaning from ECMO, discharge rate, and LVEF were significantly lower in the LI group compared to those in the nLI group. Furthermore, multiple logistic regression analysis revealed that diabetes [odds ratio (OR) = 4.338, 95% confidence interval (CI): 1.193–15.772, P = 0.026], IABP (OR = 1.526, 95% CI: 1.038–22.026, P = 0.049) and VIS-max (OR = 1.054, 95% CI: 1.024–1.085, P < 0.001) were independent risk factors for limb ischemia complications in patients who underwent V-A ECMO.ConclusionDiabetes, prevalence of IABP and VIS-max value in analyzed groups were independent risk factors for predicting limb ischemia complications in patients who underwent V-A ECMO. The cannulation strategy should be optimized during the establishment of V-A ECMO, and limb ischemia should be systematically evaluated after ECMO establishment. A DPC can be used as a salvage intervention for the complications of critical limb ischemia.

Acute Limb Ischaemia during ECMO Support: A 6-Year Experience

“…As already described, VA-ECMO is increasingly used as a rescue tool in emergency situations [ 8 ]. Previous researchers specified that limb ischaemia after VA-ECMO initiation was approximately 20% [ 19 , 20 ].…”

“…Thus far, there are few studies identifying relevant diagnostic markers of critical limb ischaemia [ 8 , 46 ]. Authors described peripheral arterial disease, diabetes and concomitant IABP therapy as predictors for acute limb ischaemia [ 8 ].…”

“…Thus far, there are few studies identifying relevant diagnostic markers of critical limb ischaemia [ 8 , 46 ]. Authors described peripheral arterial disease, diabetes and concomitant IABP therapy as predictors for acute limb ischaemia [ 8 ]. Therefore, patients with the above-mentioned risk factors must be monitored even more carefully to avoid potentially reversible complications [ 47 , 48 ].…”

“…Acute limb ischaemia is a feared complication after peripheral VA-ECMO initiation and can have a devastating impact on patients’ outcomes and the survival rate [ 8 ]. It can result in inadequate blood supply to the ipsilateral limb, which can lead to the amputation or even, in the worst case, to the patient’s death [ 5 , 9 ].…”

Elevated lactate levels and impaired lactate clearance during extracorporeal life support (ECLS) are associated with poor outcome in cardiac surgery patients

“…Additionally, the unknown role of lactate concentration during critical limb ischemia and resulting lower extremity amputation during VA-ECLS needs to be addressed. However, initial results do not show any significant differences with regard to this parameter [ 36 ]. In order to identify ischemia more accurately in the future, a Near-Infrared Spectroscopy (NIRS) Oximetry measurement should be carried out on the affected extremity in addition to the Doppler examination.…”