VAA ECMO: A Hybrid Cannulation Strategy in a Patient with Severe Peripheral Arterial Disease

Abstract

Introduction Peripheral arterial disease (PAD) can restrict vascular access options for venoarterial extracorporeal membrane oxygenation (VA ECMO). In emergent situations, a comprehensive vascular assessment is impractical, and when severe PAD is encountered, cannulation approaches may be limited. We report a successful cannulation strategy in a patient with severe PAD using bilateral femoral arterial access. Case A 69-year-old White male with ischemic cardiomyopathy with baseline EF 20-25%, coronary bypass grafting (CABG), and peripheral arterial disease (PAD) was admitted to an outside hospital for an elective redo CABG. He had post-cardiotomy shock requiring inotropes and a balloon pump. In 48 hours, he progressed to refractory cardiogenic shock and multiorgan failure with oliguria, coagulopathy, and mild cognitive impairment. VA-ECMO was emergently initiated as a potential bridge to durable ventricular assist device, pending renal recovery.After cut down, heavy circumferential calcification of the left common femoral artery (CFA) was observed, with no palpable pulse. Seldinger technique with incremental dilation was performed. However, a standard 180 cm wire met resistance and could not be advanced beyond 20 cm. Hoping this was extensive plaque, rather than a complete occlusion, a 19-French arterial cannula was placed, with a 6-French antegrade perfusion cannula in the left superficial femoral artery (SFA). ECMO was initiated and only 1 L of flow at 4000 RPM was achieved, indicating the resistance encountered likely implied a complete or critical stenosis of the left iliac artery. A second 19-French arterial cannulation in the right CFA was performed with no resistance this time. The arterial cannulae were connected in a Y configuration and ECMO resumed with roughly 3.5 L at 4000 RPM. The right common femoral vein was accessed with a 21-French venous cannula.He was extubated in less than 48 hours and did well for about 5 days, with evidence of LV recovery on ramp studies. Unfortunately, he then developed hypoxic respiratory failure, hemoptysis, recurrence of multiorgan failure, and hemodynamic instability, suspicious for septic shock. At this point, his family elected to initiate comfort measures, particularly in light of worsening cognitive status. Summary Atherosclerotic vessels pose access difficulties and risk vascular complications. As such, severe PAD often limits patient selection for VA ECMO. To the best of our knowledge, this is the first reported case utilizing a bilateral femoral arterial approach to augment a low flow state in the setting of severe PAD. Various hybrid cannulation strategies may be considered with respect to individual anatomy and broaden the patient pool eligible for VA ECMO.