LIMB PERFUSION PROTECTION STRATEGIES IN VA-ECMO: A SYTEMATIC REVIEW AND META-ANALYSIS

Abstract

BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides cardiovascular and respiratory support for patients in cardiogenic shock; yet, complications are a frequent source of morbidity and mortality. One of the most concerning complications, limb ischemia, can be potentially mitigated by limp perfusion protection strategies (LPPS). We sought to evaluate the safety and efficacy of LPPS in patients treated with peripheral VA-ECMO. METHODS AND RESULTS Searches of Ovid MEDLINE, Elsevier EMBASE, EBM Reviews – Cochrane Central Register of Controlled Trials, and Web of Science were performed to identify studies evaluating two LPPS – prophylactic insertion of a distal perfusion catheter (DPC) and choosing a small bore (< 17 Fr) arterial return cannula. Prospective and retrospective studies reporting outcomes of patients treated with peripheral VA-ECMO according to LPPS were eligible for inclusion. Two study investigators independently screened, extracted data, and assessed the quality of all included studies. From the 5,128 studies identified 22 were included in the meta-analysis. Four studies evaluated a small arterial cannula strategy and 18 evaluated prophylactic DPC insertion. Limb ischemia was reduced in patients receiving a small arterial cannula (OR 0.40, 95% CI 0.24-0.65; p= < 0.001) and in patients receiving a prophylactic DPC (OR 0.31, 95% CI 0.21-0.45; p < 0.001). Mortality was not significantly reduced with either the small cannula (OR 0.70, 95% CI 0.23-2.18; p=0.54) or prophylactic DPC strategy (OR 0.89, 95% CI 0.67-1.17; p=0.40). CONCLUSION Prophylactic insertion of a DPC or smaller bore arterial return cannula (< 17 Fr) were both associated with a reduced risk of lower limb ischemia in this analysis meta-analysis. However, we did not find a reduction in mortality with either of these strategies. Further data from prospective, randomized clinical trials are needed to confirm these findings. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides cardiovascular and respiratory support for patients in cardiogenic shock; yet, complications are a frequent source of morbidity and mortality. One of the most concerning complications, limb ischemia, can be potentially mitigated by limp perfusion protection strategies (LPPS). We sought to evaluate the safety and efficacy of LPPS in patients treated with peripheral VA-ECMO. Searches of Ovid MEDLINE, Elsevier EMBASE, EBM Reviews – Cochrane Central Register of Controlled Trials, and Web of Science were performed to identify studies evaluating two LPPS – prophylactic insertion of a distal perfusion catheter (DPC) and choosing a small bore (< 17 Fr) arterial return cannula. Prospective and retrospective studies reporting outcomes of patients treated with peripheral VA-ECMO according to LPPS were eligible for inclusion. Two study investigators independently screened, extracted data, and assessed the quality of all included studies. From the 5,128 studies identified 22 were included in the meta-analysis. Four studies evaluated a small arterial cannula strategy and 18 evaluated prophylactic DPC insertion. Limb ischemia was reduced in patients receiving a small arterial cannula (OR 0.40, 95% CI 0.24-0.65; p= < 0.001) and in patients receiving a prophylactic DPC (OR 0.31, 95% CI 0.21-0.45; p < 0.001). Mortality was not significantly reduced with either the small cannula (OR 0.70, 95% CI 0.23-2.18; p=0.54) or prophylactic DPC strategy (OR 0.89, 95% CI 0.67-1.17; p=0.40). Prophylactic insertion of a DPC or smaller bore arterial return cannula (< 17 Fr) were both associated with a reduced risk of lower limb ischemia in this analysis meta-analysis. However, we did not find a reduction in mortality with either of these strategies. Further data from prospective, randomized clinical trials are needed to confirm these findings.