Vascular complications in patients with peripheral veno-arterial extracorporeal membrane oxygenation: clinical-echocardiographic characteristics and predictors

Abstract

Abstract Introduction Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. Lower limb ischemia associated with peripheral VA ECMO is frequent, and is considered a serious complication with a significant impact on the morbidity and mortality. Purpose The aim of this study was to describe the clinical-echographic parameters and analyze predictors related to vascular complications in patients with peripheral VA ECMO. Methods The study was a single-center cohort analysis. It included all consecutive adult patients with peripheral femoro-femoral VA ECMO due to refractory cardiogenic shock (CS) or cardiac arrest (CA) between March 2014 and December 2022. Patients with central cannulation were excluded. The primary endpoint was evidence of vascular complications resulting in surgical intervention. A multivariate logistic regression model was used to adjust for variables of interest. Results The study included 83 patients (65± 12 years, 54% male). The main previous diagnosis was necrotic ischemic cardiomyopathy (33%), and the most frequent indication was postcardiotomy (40.9%), mainly in SCAI D (85.5%). Cardiopulmonary resuscitation was performed in 18.1%. Femoro-femoral cannulation was percutaneuos in 95.2%. Most patients had intra-aortic balloon pump (87.1%) and distal percutaneous cannula (88.8%). A total of 18 patients presented vascular complications (21.7%): 2 patients (11.1%) amputation, 5 patients (27.7%) compartment syndrome requiring fasciotomy, 9 patients (50.0%) thrombectomy, and 2 patients (11.1%) a surgical resolution post decannulation due to AV fistula. The median duration of VA ECMO was 5 days (IQR 2-8). Among the ultrasound variables, the systolic peak velocity (SPV) in the distal territory (tibioperoneal segment) had a median of 22 cm/sec (IQR 10-30). Pulsatile spectral Doppler flow in the cannulated limb was evidenced in 42 patients (50.6%) of total population, and only in 3 patients (16.6%) with vascular complications. The survival rate from VA ECMO was 57.8%, and the survival rate to discharge 42.1%. In-hospital mortality of patients with or without vascular complications did not show statistically significant differences (54.2 % vs 58.2 %, p= 0.26). After multivariate analysis, distal territory SPV less than 20 cm/sec (OR: 2.1, 95%CI: 1.3 – 12.1, p: 0.03), as well as history of previous vascular disease, were associated with a higher number of vascular complications (OR: 2.5, 95% CI: 1.5 – 10.1, P; 0.02). Conclusions Vascular complications in patients with femoro-femoral VA ECMO remain frequent and constitute an important cause of morbidity. Decreased peak systolic velocities in the cannulated tibio-peroneal territory, as well as a history of previous vascular disease were significantly associated with a higher rate of vascular complications.