Hypothermic, Initially Oxygen-Free, Controlled Limb Reperfusion for Acute Limb Ischemia

Abstract

Controlled limb reperfusion has been shown to prevent the deleterious effects of ischemia-reperfusion (IR) syndrome following revascularization of acute limb ischemia (ALI). To reduce the production of cell-toxic oxygen-free radicals, we have established a new initially oxygen-free, hypothermic, heparin-coated perfusion and hemofiltration system and report on our first results. In a retrospective single-center study, controlled limb reperfusion was applied in 36 patients (64.7 ± 15 years) with ALI of category IIA to III (33.7 ± 20.7 hr ischemic time). 52.8% had central (aortic and bifurcation) and 47.2% had peripheral (common iliac artery and distal) vascular occlusions. The common femoral artery and vein were cannulated, and a hypothermic (22°C), initially oxygen-free, potassium-free ringer's solution was perfused using a heparin-coated extracorporeal membrane oxygenation (ECMO) and hemofiltration system with low-dose heparinization. Thirty-day mortality, clinical recovery of neurological dysfunction, limb amputation, and fasciotomy rate were analyzed. Laboratory parameters associated with ischemia and IR injury were determined. Average perfusion time was 94 ± 35 min. Thirty-day mortality was 27.8%. 55.5% of patients showed complete recovery of motor and sensory dysfunction. A total of 27.8% of patients developed a compartment syndrome and required fasciotomy. Lower leg amputation was necessary in 11.1% of patients. Lactate levels were reduced in ischemic limbs by 25.3% within 60 min (P < 0.05). Preoperative negative base excess of -1.96 ± 0.96 mmol/L was equalized after 12 hr (P < 0.05), while pH stayed balanced at 7.4. Serum potassium stayed within normal limits throughout 24 hr, and therefore systemic hyperkalemia was prevented and imminent metabolic acidosis was corrected. An initially oxygen-free, hypothermic, heparin-coated ECMO counteracts local and systemic effects of IR injury. Reduced mortality and morbidity might result from this new treatment, although this could not be conclusively proven in our study. A prospective, randomized controlled trial is needed to prove superiority of this new concept.