Preclosure technique versus arterial cutdown after percutaneous cannulation for venoarterial extracorporeal membrane oxygenation

Abstract

Background: Arteriotomy repair through the preclosure technique during elective arterial access procedures is well documented. Outcomes associated with application of this technique to the removal of arterial access cannulas in patients undergoing urgent venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not previously been reported.Methods: We reviewed the records of consecutive patients who required VA-ECMO for cardiogenic shock. Patients were compared by use of the preclosure device (Perclose ProGlide Suture-Mediated Closure System; Abbott Vascular, Abbott Park, Ill) at time of VA-ECMO cannulation. The rate of limb complications (composite of limb ischemia, infection, and site necrosis) and secondary end points of bleeding events, pseudoaneurysm, distal part embolization, and intensive care unit length of stay after decannulation were compared between the groups.Results: Ninety-nine consecutive patients managed with VA-ECMO were identified and the preclosure device was utilized in 51 of these patients. Preclosure device failure occurred in 5 instances (9.8%) and was successfully managed with surgical repair in 4 cases and endovascular intervention in another. Use of the preclosure device was associated with both fewer limb complications (odds ratio, 0.19; 95% confidence interval, 0.03-0.78) and bleeding events (odds ratio, 0.21; 95% confidence interval, 0.04-0.89). Pseudoaneurysm (n ¼ 0) and distal part embolization (n ¼ 1) were infrequently encountered in the cohort and no difference in intensive care unit length of stay after decannulation was noted between the groups.Conclusions: In this cohort, use of the preclosure technique in weaning from VA-ECMO was technically feasible, safe, and associated with an approximate 80% lower likelihood of limb complications and bleeding events compared with surgical removal. (JTCVS Techniques 2021;-:1-9)Preclosure technique for VA-ECMO via the Perclose ProGlide suture-mediated closure system.

Case report: Total percutaneous post-closure of femoral arterial access sites after veno-arterial extracorporeal membrane oxygenation

“…Total percutaneous suture arteriotomy wounds minimize invasiveness compared with femoral cutdown access repair. A most recent single-center study using Perclose ProGlide suture-mediated system with preclose technique shows satisfactory successful closure rates with fewer limb complications and bleeding events and a reduction in total operative time without increasing hospital stay length ( 5 ). While we propose that potential defects are the following: (1) Preclose technique increases operational complexity and likelihood of error during VA-ECMO implantation of cannulation and prolongs the whole operating time, which means operators should be adequately strictly trained.…”

“…Therefore, the device facilitates various vascular interventions and the Proglide deployed prior to the insertion of the large bore devices is often referred as “Perclose technique.” The preclose technique with perclose Proglide (PP) allows for rapid arteriotomy closure after percutaneous interventions as it is used immediately once the procedure has concluded. They allow early ambulation and discharge after groin puncture and mitigate patient discomfort from extended manual compression ( 5 , 6 ). Proglide-assisted closure devices in preclosure have been popular proposed and applied to VA-ECMO decannulation ( 6 – 9 ), which minimize invasiveness, shorten procedure time, release post-operative pain, and decrease the risk of wound complications.…”

How to Do Weaning and Decannulation in Adult Cardiac

“…In an effort to reduce the rates of vascular complications at the time of VA-ECMO decannulation and avoid the need for traditional surgical vascular repair, percutaneous techniques for closure of arterial cannulation sites utilizing several vascular closure systems have been employed by a number of centers [13].…”

“…Chandel et al reported the use of a pre-closure technique was associated with a significant decrease in limb complications and bleeding events with an estimated 81% and 79% decreased likelihood of these complications, respectively, compared with surgical removal [13]. Data from prior cohorts have documented the utility of this technique in the removal of arterial sheaths of sizes ranging from 5 Fr to 24 Fr [13]. The main benefit of using this technique is the avoidance of a groin incision, which may be susceptible to wound infection, poor healing, and lymph leakage [14].…”

Manual Compression versus Suture-Mediated Closure Device Technique for VA-ECMO Decannulation

“…Previous meta-analyses reported major vascular complications including severe bleedings, limb ischemia, compartment syndrome, and extremity amputation in almost 20% of all cases [ 1 ]. Another retrospective study could show a lower rate of complications for percutaneous techniques compared to surgical approaches [ 2 ]. A first randomized study of Danial et al found fewer local infections, similar rates of ischemia and sensory motor complication, as well as improved 30-day survival if decannulation was performed percutaneous with manual compression instead of a surgical approach [ 3 ].…”