Occurrence, Predictors, and Management of Late Vascular Complications following Extracorporeal Membrane Oxygenation

Abstract

BackgroundVascular complications (VC) associated with Extracorporeal Membrane Oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VC following ECMO; this study aims to assess occurrence and management practices of late VC following discharge. MethodsA retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1st 2019 and December 31st 2020. Primary outcomes were to categorize and determine the rate late VC. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations. ResultsA total of 229 patients were identified, of which 50.6% (n=116) survived until discharge. Late VC occurred in 7.8% of the surviving cohort (n=9/116); with a median time until presentation of 150 days (IQR 83-251). The most common late VC was infection (n=5, 55.6%) followed by progression to limb threatening ischemia (n=4, 44.4%). Urgent procedures were required in 55.6% of patients (n=5), while 44.4% (n=4) were elective interventions. Interventions performed for management of late VC included lower extremity arterial revascularization (n=6, 66.7%), major (n=1, 11.1%) or minor amputation (n=1, 11.1%), and wound debridement (n=1, 11.1%). The majority of patients presenting with late VC had initially been cannulated for peripheral-VA ECMO (n=8, 88.9%) and 1 patient (11.1%) was cannulated for peripheral-VV ECMO. VC during index hospitalization were seen in 77.8% (n=7) of patients returning with late VC. Odds for late VC were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal-cardio-pulmonary resuscitation (E-CPR) (OR 8.4, p=0.016) and in cases were patient had experienced an index VC during index hospitalization (OR 19.3, p=0.001). ConclusionLate vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb.