Pitfalls of cannulation for extracorporeal life support: review of the literature and illustrative case presentation

Abstract

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) are an increasingly established advanced therapy for emerging severe lung and/or cardiocirculatory dysfunction or failure. Several reports have provided evidence for a potential benefit in prognosis by ECLS in cases of cardiogenic shock including cardiopulmonary resuscitation. Routine use in specialized centers reduces the incidence of negative side effects (e.g., vascular/ischemic, embolic, hemorrhagic, hemolytic and, furthermore, septic). Vascular complications like not only limb ischemia but also hypoxia proximal to the cannulation site up to complete sectorial hypoxia called "harlequin phenomenon" could refer to be a major adverse event in ECLS which, therefore, should be limited primarily to cardiocirculatory indications. Here we report on a case with "harlequin phenomenon" after ECLS implementation as a relevant complication of the mode of cannulation and review benefits and risks of commonly used variants of vascular access.

Principles and indications of extracorporeal life support in general thoracic surgery

“…Complications are inherent to the need for vascular cannulation and the anticoagulation required for ECLS use (73)(74)(75). The overall risk of complications has decreased over the past few years and will continue to improve with increasing experience.…”

A quantified description of the interactions between the native cardiovascular system and femoro‐femoral versus femoro‐axillary extracorporeal life support using descending thoracic aorta velocity time integral

“…In the peripheral approach, the site for arterial cannula placement classifies the VA‐ECLS into femoro‐femoral (FF‐VA‐ECLS) and femoro‐axillary (FA‐VA‐ECLS) ECLS. The femoro‐femoral approach is more commonly used . The preference for one technique over the other depends on center experience .…”

“…Another potentially severe complication in FF‐VA‐ECLS patients is the so‐called “harlequin syndrome”—characterized by hypoxemia of the upper body, including the brain, which appears when cardiac function recovers faster than lung capacity to adequately oxygenate the blood . In some reports, it was necessary to switch from FF‐VA‐ECLS to FA‐VA‐ECLS in order to improve upper body oxygenation …”

“…The femoro-femoral approach is more commonly used. 10 The preference for one technique over the other depends on center experience. 11 Because of its retrograde arterial outflow into the aorta, FF-VA-ECLS may increase left ventricular (LV) afterload, thus potentially aggravating LV dysfunction, particularly in patients with preexistent severe LV systolic dysfunction.…”

“…15 In some reports, it was necessary to switch from FF-VA-ECLS to FA-VA-ECLS in order to improve upper body oxygenation. 10 Theoretically, FA-VA-ECLS could be considered as more "physiological" because of its anterograde arterial blood outflow, with no increase in LV afterload. A pig cardiac arrest model study showed adequate brain oxygenation for both FF-VA-ECLS and femoro-subclavian artery ECLS, the coronary perfusion being better for FF-VA-ECLS.…”