Distal Perfusion Catheter Research Articles

Factors Associated with Ipsilateral Limb Ischemia in Patients Undergoing Femoral Cannulation Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is an important life-saving modality for patients with cardiopulmonary failure. Vascular complications, including clinically significant limb ischemia, may occur as a result of femoral artery cannulation for venoarterial (VA) ECMO. This study examines our institutional experience with femoral VA ECMO and the development of ipsilateral limb ischemia. We performed a retrospective review of all consecutive patients undergoing femoral VA ECMO between 2011 and 2016. The primary endpoint was clinical evidence of limb-threatening ischemia. Multivariate logistic regression analysis was used to identify predictors for limb ischemia after cannulation. Between March 2011 and September 2016, 154 patients underwent femoral cannulation for VA ECMO. Overall in-hospital mortality was 59.7%. Clinically significant ipsilateral limb ischemia occurred in 34 (22%) patients; 7 required four-compartment fasciotomy, and 3 of these patients required amputation. On univariate analysis, a history of pulmonary disease, peripheral arterial disease, and stroke or transient ischemic attack was significantly associated with clinical limb ischemia. On multivariate analysis, younger age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.99), diabetes (OR, 2.77; 95% CI, 1.08-7.12), pulmonary disease (OR, 3.86; 95% CI, 1.38-10.78), and peripheral arterial disease (OR, 13.68; CI, 2.75-68.01) were associated with limb ischemia. Lack of prophylactic distal perfusion catheter and arterial cannula size were not independently associated with limb ischemia. Femoral ECMO cannulation can be associated with significant limb ischemia necessitating surgical intervention. Younger patients, as well as those with a history of diabetes, pulmonary disease, and peripheral arterial disease, may be at increased risk for this complication.

Vascular Complications and Use of a Distal Perfusion Cannula in Femorally Cannulated Patients on Extracorporeal Membrane Oxygenation.

Femoral arterial cannulation in adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) predisposes patients to ipsilateral limb ischemia. Placement of a distal perfusion catheter (DPC) is one of few techniques available to prevent or manage this complication. Although frequently used, the indications for and timing of DPC placement are poorly characterized, and no guidelines are available to guide its use. The purpose of this study was to compare the incidences of vascular complications and limb ischemia between patients who did and did not receive a DPC at the time of primary ECMO cannulation. Between June 2009 and April 2015, 132 adults underwent VA ECMO cannulation at our institution. Of the 80 femoral cannulations comprising this retrospective single-center study cohort, 14 (17.5%) received a DPC at the time of primary cannulation. Demographics, indications for ECMO, and cardiovascular history and risk factors were not significantly different between comparison groups. Median arterial cannula size was 17 French in both groups. Vascular complications occurred in 2 of the 14 patients with initial DPC (14.3%) compared with 21 of 66 without initial DPC (31.8%; p = 0.188). Limb ischemia occurred in 2 of 14 patients in the DPC group (14.3%) and 15 of 66 in the non-DPC group (22.7%; p = 0.483). In-hospital mortality was comparable between groups. DPC placement at the time of primary cannulation may lower the incidence of limb ischemia. The benefit of DPC placement once evidence of limb ischemia is apparent remains unclear.

Identifying the Risk Factor and Prevention of Limb Ischemia in Extracorporeal Membrane Oxygenation with Femoral Artery Cannulation.

Application of extracorporeal membrane oxygenation (ECMO) for life support has been widely used in various fields of resuscitation. When the common femoral artery (CFA) is used during cannulation for ECMO support in adults, it is often complicated by limb ischemia. Placement of distal perfusion catheter (DPC) can reduce the incidence of limb ischemia and increases the likelihood of limb preservation, but selection criteria is uncertain. This is a retrospective study. Data was reviewed for patients in one medical center who were supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO) via CFA cannulation percutaneously between January 2008 and June 2014. Two groups were divided into no-ischemia and ischemic limb. Age, sex, height, weight, body surface area (BSA), cannula size, femoral artery diameter, comorbidity, acute physiology and chronic health evaluation (APACHE) II score, vasoactive-inotropic score (VIS) and mortality rate were analyzed. Doppler was used by measuring the distal pulsation in the dorsalis pedis and posterior tibial artery to select the patients. A DPC was prophylactically inserted percutaneously into the superficial femoral artery for antegrade flow to the extremity in the patients who met selection criteria. 139 (43.6%) patients were included in the study and limb ischemia occurred in 46 (33%) of 139. There was a significant difference between the no-ischemia group and the ischemia group in age (55.5 ± 14.2 versus 63.2 ± 13.2; P < .001), common femoral artery diameter (0.82 ± 0.14 versus 0.63 ± 0.17; P < .001 ), known peripheral artery occlusive disease (9% versus 24%; P < .001) and VIS (12.1 ± 8.1 versus 15.8 ± 10.1; P < .001). Mortality rate was higher in the ischemia group (46% versus 26% ; P < .001). 11 patients who met the selection criteria had a DPC prophylactically inserted and no ischemia limb occurred. Smaller common femoral artery diameter (≤6.3 cm); known peripheral arterial occlusive disease; higher VIS (≥15.8); absence of distal pulsation pre-cannulation or immediately after post-cannulation or 4 hrs later have higher risk of limb ischemia when CFA cannulation is used for VA-ECMO. Due to this, the mortality and morbidity rate increases when limb ischemia occurs. A DPC should be prophylactically inserted in high-risk patients who meet selection criteria.

Survey of the American Pediatric Surgical Association on cannulation practices in pediatric ECMO

AimsExtracorporeal membrane oxygenation (ECMO) is a commonly used modality of life support for children with cardiopulmonary failure. Consensus on pediatric cannulation strategies and management does not currently exist. The goal of this study was to investigate individual surgeon approaches towards ECMO cannulations in children. MethodsA 21-question online survey was developed and disseminated to the American Pediatric Surgical Association (APSA) membership. Participant responses were summarized as counts and percentages. Effect of ECMO volume and surgeon experience on responses was assessed. ResultsThere were 252 APSA members who participated in this study for a response rate of 21%, with 225 (89.3%) performing ECMO. Sixty respondents (28.3%) reported using neck vessels exclusively for cannulation regardless of age or weight of the patient. After neck decannulation, 13 (6.6%) repaired the carotid artery for all patients, and 21 (10.7%) repaired only for children older than 5years. Of those performing femoral cannulation, 56 (26.4%) would perform at 5years or older and 66 (31.1%) at 12years. The most common challenge for femoral cannulation was the need for distal perfusion (n=119; 59.8%). Assistance from vascular surgery was requested by 32 (16.4%) for distal perfusion catheter placement, and by 79 (40.5%) for decannulation. Regarding femoral cannulation, lack of training was more likely to be a challenge if performing <5 cannulations per year (25.2% vs 12.5%; p=0.03). Surgeons with <10years of experience were more likely to consult vascular surgery compared to those with >10years of experience (18.5% vs 8%; p=0.03). ConclusionConsiderable variation exists in individual surgeon cannulation practices in pediatric ECMO, in particular in the management of school age and adolescent VA ECMO. Mixed approaches across several ECMO management case study questions indicate that further work is needed to evaluate specific risks with cannulations in children. Level of evidenceIV

Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation

ObjectiveVenoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. MethodsWe conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. ResultsA total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. ConclusionsLimb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.

Routine Use of Distal Arterial Perfusion in Pediatric Femoral Venoarterial Extracorporeal Membrane Oxygenation.

Lower-extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single-center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty-nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.

A retrospective cohort analysis of percutaneous versus side-graft perfusion techniques for veno-arterial extracorporeal membrane oxygenation in patients with refractory cardiogenic shock.

This study was designed to compare vascular complications and the outcomes of ultrasound (US)-guided percutaneous cannulation with distal perfusion catheter (PC-DP) and arterial side-graft perfusion (SGP) techniques in patients who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock (RCS). We conducted a retrospective, observational cohort study of consequtive patients with RCS treated with VA-ECMO at a single transplant center from March 2010 until August 2015. Overall, 148 patients underwent VA-ECMO for RCS (99 men, aged 56.6 ± 12.0 years; BSA, 1.85 ± 0.19). Patients were categorized based on VA-ECMO perfusion technique into PC-DP via femoral artery and SGP via axillary/femoral artery groups. The median duration of VA-ECMO support was 5 days (range, 8 hours-80 days). Hospital mortality (PC-DP group, 54.7%; SGP group, 64.4%; p=0.23) and overall ECMO survival (PC-DP group, 36.9%; SGP group, 32.2%; p=0.47) was similar between the groups. There were no significant between-group differences in the rate of acute limb ischemia (PC-DP group, 4/75, 5.3%; SGP group, 2/73, 2.7%; p=0.68). However, the rate of surgical/cannulation site bleeding (PC-DP, 9/75 (12%) vs SGP, 18/73 (24.7%), p=0.05) and hyperperfusion syndrome (PC-DP, 2/75 (2.7%) vs SGP, 22/73 (30.1%),p=0.001) were higher in the SGP group than in the PC-DP group. We observed no significant difference in major vascular complications or survival between patients who underwent the PC-DP technique and those who underwent arterial SGP.

The Impact of Vascular Complications on Survival of Patients on Venoarterial Extracorporeal Membrane Oxygenation

There are various factors that can influence the survival of patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). Vascular complications from femoral cannulation are common and are potentially serious. We analyzed the impact of vascular complications on survival of patients receiving VA ECMO. Patients supported with VA ECMO by means of femoral cannulation from October 2010 to November 2014 were enrolled in this study. Data were gathered retrospectively by reviewing our institutional database. Patients were separated into two groups depending on thepresence of major vascular complications, defined as patients who required surgical intervention. We evaluated predisposing factors for vascular complications and compared survival of patients in each group. There were 84 patients enrolled in the study. The rates of overall ECMO survival and survival to hospital discharge were 60% and 43%, respectively. Major vascular complications requiring surgical intervention were seen in 17 (20%) patients. Ten patients (12%) had compartment syndrome requiring prophylactic fasciotomy, and 10 patients (12%) had bleeding or hematoma requiring surgical exploration. The only significant predisposing factor for vascular complications was the absence of a distal perfusion catheter (odds ratio, 14.8; p= 0.03). The rate of survival to discharge was 18% and 49% in patients with and without vascular complications, respectively (p= 0.02). Vascular complications were an independent factor of significantly worse survival in patients receiving VA ECMO by multivariate analysis (hazard ratio, 2.17; p= 0.02). Vascular complications negatively affect survival in patients receiving VA ECMO support by means of femoral cannulation. The utilization of a distalperfusion catheter can decrease the incidence of complications.

Safety and Efficacy of Distal Perfusion Catheterization to Prevent Limb Ischemia after Common Femoral Artery Cannulation for Extracorporeal Membrane Oxygenation

의해 다리 관류가 저하되면 연조직의 허혈과 또한 심한 경우 경 Purpose: The extracorporeal membrane oxygenation (ECMO) cannula has the potential for obstructing flow to the lower limb, thus causing severe ischemia and possible limb loss. We evaluated the safety and clinical efficacy of percutaneous distal perfusion catheterization in preventing limb ischemia. Materials and Methods: Between March 2013 and February 2015, 28 patients with distal perfusion catheterization after ECMO were included in this retrospective study. The technical success was evaluated by Doppler ultrasound at the popliteal level after saline injection via distal perfusion catheter. Clinical success was assessed when at least one of the following conditions was met: restoration of continuous peripheral limb oximetry value or presence of distal arterial pulse on Doppler ultrasound evaluation or resolution of early ischemic sign after connecting the catheter with ECMO. Results: Twenty-six patients with early ischemia were successfully cannulated with a distal perfusion catheter (92.8%). Clinical success was achieved in 12/28 (42.8%) patients; 8/10 (80.0%) patients with survival duration exceeding 7 days and 4/18 (22.2%) patients with survival duration less than 7 days, respectively. Conclusion: A percutaneous distal perfusion catheter placement was a feasible tool with safety and efficacy in preventing lower limb ischemia for patients with prolonged common femoral arterial cannulation for ECMO. Index terms Extracorporeal Membrane Oxygenation Ischemia Perfusion Catheter Spectroscopy Near-Infrared

RR8. Outcome of Rectus Femoris Muscle Flaps for Femoral Arterial Graft Complications

Objectives: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Because large cannulas (16-24F) are necessary to achieve adequate oxygenation, the femoral artery is the most common access site. Unfortunately, femoral cannulation has been associated with limb complications (10%-70%), including ischemia, limb loss, and compartment syndrome. This study aimed to evaluate these complications and management related to limb salvage. Methods: A retrospective review was conducted of 91 consecutive patients requiring VAECMO via femoral cannulation from July 2010 until January 2015. At the time of cannulation, most patients had percutaneous placement of distal arterial perfusion catheters (DPC). After cannulation, all patients were monitored by a near-infrared spectroscopy (NIRS) algorithm and hourly lower extremity examination by trained cardiac intensive care nursing staff, with immediate notification of any change from baseline. ECMO decannulation involved a femoral cutdown with arteriotomy closure by either primary repair or patch angioplasty with bovine pericardium. Study end points included limb ischemia, compartment syndrome requiring fasciotomies, and limb loss. Results: Ninety-one patients were supported with VA-ECMO with femoral arterial cannula sizes from 1624F. Mean length of time on ECMO was 9.1 days (range, 1-40 days). Percutaneous DPC was placed immediately in 62 of 91 patients, with no subsequent ischemia. Of the 29 patients without initial DPC placement, 12 (41.4%; 13.2% of all VA ECMO) developed acute ischemia. Two patients subsequently had DPC placement only, 5 had DPC placement and fasciotomies, 4 had fasciotomies only, and 1 patient required amputation after presenting with acute ischemia after cannulation at another hospital. After DPC placement, all patients had resolution of limb ischemia. The remaining 17 patients without DPC placement experienced no vascular compromise. Overall survival in our VAECMO population was 64%; in patients with limb complications, mortality was 75%. Conclusions: Historically, femoral VA-ECMO has been associated with significant limb ischemic complications. A systematic protocol including NIRS monitoring, trained intensive care nursing staff, DPC placement, decannulation with primary repair of arteriotomies or patch angioplasty can decrease rates of limb ischemia leading to limb loss.

Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem

Purpose Extracorporeal Life Support Organization Registry data confirm that the number of pediatric patients being supported by extracorporeal membrane oxygenation (ECMO) is increasing. To minimize the potential neurologic effects of carotid artery ligation, the common femoral artery (CFA) is frequently being used for arterial cannulation. The cannula has the potential for obstructing flow to the lower limb, thus increasing ischemia and possible limb loss. We present a single institution's experience with CFA cannulation for venoarterial (VA) ECMO and ask whether any precannulation variables correlate with the development of significant limb ischemia. Methods We reviewed all pediatric patients who were supported by VA ECMO via CFA cannulation from January 2000 to February 2010. Limb ischemia was the primary variable. The ischemia group was defined as the patients requiring an intervention because of the development of lower extremity ischemia. The patients in the no-ischemia group did not develop significant ischemia. Continuous variables were reported as medians with interquartile ranges and compared using Mann-Whitney U tests. Differences in categorical variables were assessed using χ 2 testing (Fisher's Exact). Statistical significance was assumed at P < .05. Results Twenty-one patients (age, 2-22 years) were cannulated via the CFA for VA ECMO. Significant ischemia requiring intervention (ischemia group) occurred in 11 (52%) of 21. In comparing the 2 groups (ischemia vs no ischemia), no clinical variables predicted the development of ischemia ( Table 1). In the ischemia group, 9 (81%) of 11 had a distal perfusion catheter (DPC) placed. Complications of DPC placement included one case of compartment syndrome requiring a fasciotomy and one patient requiring interval toe amputation. Of the 2 patients in the ischemia group who did not have a DPC placed, 1 required a vascular reconstruction of an injured superficial femoral artery and 1 underwent a below-the-knee amputation. Mortality was lower in the ischemia group (27% vs 60%). Conclusions Limb ischemia remains a significant problem, as more than half of our patients developed it. The true incidence may not be known as a 60% mortality in the no-ischemia group could mask subsequent ischemia. Although children are at risk for developing limb ischemia/loss, no variable was predictive of the development of significant limb ischemia in our series. Because of the inability to predict who will develop limb ischemia, early routine placement of a DPC at the time of cannulation may be warranted. However, DPCs do not completely resolve issues around tissue loss and morbidity. Prevention of limb ischemia/loss because of CFA cannulation for VA ECMO continues to be a problem that could benefit from new strategies.

Prognostic Factors for Adult Patients Receiving Extracorporeal Membrane Oxygenation as Mechanical Circulatory Support—A 14‐Year Experience at a Medical Center

Extracorporeal membrane oxygenation (ECMO) is a resource-consuming and highly invasive treatment. There were 1100 ECMO cases at the National Taiwan University Hospital between August 1994 and November 2008. Of these, 607 were adults (>18 years old) who received ECMO as mechanical circulatory support. In this study, patient characteristics and complications during the ECMO course were evaluated for their correlation with prognosis. The following factors were significantly different between survivors and nonsurvivors: age, coronary artery disease, diabetes mellitus, brain death, stroke during ECMO, the need for dialysis during ECMO, pre-ECMO infection, hypoglycemia, acidosis, alkalosis, the need for a distal perfusion catheter, and the amount of red blood cells transfused. Six independent predictors of mortality were identified: age, stroke, the need for dialysis during ECMO, pre-ECMO infection, hypoglycemia, and alkalosis. Our institution has comparatively extensive experience with adult patients, which may be quite different from other medical centers with respect to distribution of patient age. The findings should lead to better utilization of ECMO for adult patients in the future.

Pressure criterion for placement of distal perfusion catheter to prevent limb ischemia during adult extracorporeal life support

Pressure criterion for placement of distal perfusion catheter to prevent limb ischemia during adult extracorporeal life support

Invited commentary

Fortunately, postcardiotomy mechanical support is required in only 0.5% to 1.0% of cardiac operations. Extracorporeal membrane oxygenation is very versatile, providing both cardiac and pulmonary support, is portable, easy to run, and inexpensive. Vascular access can be obtained through the peripheral circulation. However, a tremendous amount of resources will be utilized to support patients who die 75% of the time. How can information provided in this and other recently published series be used to optimally manage patients? Although peripheral access is often convenient, it is associated with a very high rate of vascular complications of the lower extremity. We have utilized a distal limb perfusion catheter in the superficial femoral artery, while Doll has recommended anastamosing a 6-mm hemashield graft to the common femoral artery. Central aortic cannulation avoids peripheral vascular injuries; however, it often requires the sternum to remain open and can be associated with bleeding from around the cannulas. Attention to detail at this step of the operation will reduce bleeding and many of the complications listed in Table 4. Intraaortic balloon pump counterpulsation should be used in all patients on ECMO support and is associated with an improvement in survival in this series, as well as in our experience. The exact mechanism for this benefit is not known. In addition to decreasing the afterload on the heart, it may improve visceral organ perfusion thus reducing the severity of multisystem organ failure. Survival is poor for patients who are older, specifically those who are over the age of 65, and who have had a preoperative myocardial infarction, diabetes, decompensated congestive heart failure or cardiogenic shock, and, in our experience, thoracic aortic operations. It is noteworthy that 95% of Doll's patients undergoing aortic valve replacement and coronary bypass grafting and 90% of patients listed in the “other” category (pulmonary embolectomy, ventricular septal defect closure, LV and aortic aneurysm repairs) also succumbed after ECMO support. The more complex the procedure, the less likely the patient will survive. If myocardial recovery is not evident within 48–72 hours, the patient should be assessed for more advanced mechanical circulatory support as more than two thirds of patients who do not survive ECMO support have extensive irreversible myocardial injury. This approach can dramatically improve survival. If the patient is not a candidate for advanced support, is elderly, or has preoperative comorbidities, prolongation of ECMO beyond a few days is not justifiable because survival is very unlikely. ECMO can undoubtedly save the lives of patients requiring postcardiotomy support, but device related complications must be minimized and we need to have realistic expectations for survival.

External shunt for off-pump coronary artery bypass grafting: distal coronary perfusion catheter

We invented a simple external shunt catheter for off-pump coronary artery bypass grafting. This catheter maintains coronary perfusion from femoral artery, prevents ischemia, reduces back-bleeding, and acts as a suture guide by preventing accidental missuturing of the posterior coronary wall. The insertion and withdraw technique is easier than intraluminal shunt. This catheter would be a useful tool for myocardial protection during off-pump revascularization.