Extracorporeal Life Support Cannulation Research Articles

Continuous near-infrared reflectance spectroscopy monitoring to guide distal perfusion can minimize limb ischemia surgery for patients requiring femoral venoarterial extracorporeal life support

BackgroundPatients requiring femoral venoarterial (VA) extracorporeal life support (ECLS) are at risk of distal lower limb hypoperfusion and ischemia of the cannulated leg. In the present study, we evaluated the effect of using continuous noninvasive lower limb oximetry with near-infrared reflectance spectroscopy (NIRS) to detect tissue hypoxia and guide distal perfusion catheter (DPC) placement on the rates of leg ischemia requiring surgical intervention. MethodsWe performed a retrospective analysis of patients who had undergone femoral VA-ECLS at our institution from 2010 to 2014 (pre-NIRS era) and 2017 to 2021 (NIRS era). Patients who had undergone cannulation during the 2015 to 2016 transition era were excluded. The baseline characteristics, short-term outcomes, and ischemic complications requiring surgical intervention (eg, fasciotomy, thrombectomy, amputation, exploration) were compared across the two cohorts. ResultsOf the 490 patients included in the present study, 141 (28.8%) and 349 (71.2%) had undergone cannulation before and after the routine use of NIRS to direct DPC placement, respectively. The patients in the NIRS cohort had had a greater incidence of hyperlipidemia (53.7% vs 41.1%; P = .015) and hypertension (71.4% vs 60%; P = .020) at baseline, although they were less likely to have been supported with an intra-aortic balloon pump before ECLS cannulation (26.9% vs 37.6%; P = .026). These patients were also more likely to have experienced cardiac arrest (22.9% vs 7.8%; P ≤ .001) and a pulmonary cause (5.2% vs 0.7%; P = .04) as an indication for ECLS, with ECLS initiated less often for acute myocardial infarction (15.8% vs 34%; P ≤ .001). The patients in the NIRS cohort had had a smaller arterial cannula size (P ≤ .001) and a longer duration of ECLS support (5 vs 3.25 days; P ≤ .001) but significantly lower rates of surgical intervention for limb ischemia (2.6% vs 8.5%; P = .007) despite comparable rates of DPC placement (49.1% vs 44.7%; P = .427), with only two patients (1.1%) not identified by NIRS ultimately requiring surgical intervention. ConclusionsThe use of a smaller arterial cannula (≤15F) and continuous NIRS monitoring to guide selective insertion of DPCs could be a valid and effective strategy associated with a reduced incidence of ischemic events requiring surgical intervention.

Minimally Invasive Central Cannulation for Extracorporeal Life Support: The Uniportal and Subxiphoid Approach.

Extracorporeal life support (ECLS) for circulatory and/or respiratory failure is improving. Currently, invasive sternotomies or rib-spreading thoracotomies are used for central cannulation of the heart and great vessels. Although peripheral cannulation of the extremities is often used, this approach may result in immobility and unintentional dislodgement. Less invasive methods for central cannulation are needed to achieve long-term ECLS. The objective of this study was to develop 2 different minimally invasive approaches for central thoracic cannulation. Porcine hearts were positioned in a plastic thoracic model. An endoscopic camera and multiple endoscopic instruments were used. Both access points, uniportal (lateral) and subxiphoidal, were simulatively investigated. A novel cannulation method using purse string sutures, a custom-made endoscopic puncture tool, guidewires, and dilator-assisted cannulas was developed. Simulations were tested in a closed circuit regarding leak tightness. The uniportal approach allowed a cannulation of the aorta, inferior vena cava, right atrium, and main pulmonary artery. Cannulation of the right branches of the pulmonary artery and vein was also possible. From the subxiphoid approach, cannulation of the aorta, main pulmonary artery, and both atria were possible. Subsequent evaluation and leakage tests revealed no damage to the surrounding structures and tightly sealed cannulation sites. The uniportal approach was also successfully performed in a human cadaver to connect the aorta and right atrium with cannulas from the subxiphoidal space. Both uniportal and subxiphoid central cannulation of potential sites for ECLS were feasible. This study encourages further investigation and potential clinical translation of minimally invasive central organ support.

Inadvertent cannulation of the azygos vein during eCPR

Extracorporeal life support cannulation during active cardiopulmonary resuscitation (eCPR) is challenging at best. We report a CASE of inadvertent cannulation of the azygos vein during eCPR in a neonate.

Transition From Temporary to Durable Circulatory Support Systems

BackgroundThe decision to implant durable mechanical circulatory systems (MCSs) in patients on extracorporeal life support (ECLS) is challenging due to expected poor outcomes in these patients. ObjectivesThe aim of this study was to identify outcome predictors that may facilitate future patient selection and decision making. MethodsThe Durable MCS after ECLS registry is a multicenter retrospective study that gathered data on consecutive patients who underwent MCS implantation after ECLS between January 2010 and August 2018 in 11 high-volume European centers. Several perioperative parameters were collected. The primary endpoint was survival at 1 year after durable MCS implantation. ResultsA total of 531 durable MCSs after ECLS were implanted during this period. The average patient age was 53 ± 12 years old. ECLS cannulation was peripheral in 87% of patients and 33% of the patients had history of cardiopulmonary resuscitation before ECLS implantation. The 30-day, 1-year, and 3-year actuarial survival rates were 77%, 53%, and 43%, respectively. The following predictors for 1-year outcome have been observed: age, female sex, lactate value, Model of End-Stage Liver Disease XI score, history of atrial fibrillation, redo surgery, and body mass index >30 kg/m2. On the basis of this data, a risk score and an app to estimate 1-year mortality was created. ConclusionsThe outcome in patients receiving durable MCS after ECLS remains limited, yet preoperative factors may allow differentiating futile patients from those with significant survival benefit.

Outcomes After Extracorporeal Life Support Cannulation in Pediatric Patients With Trisomy 13 and Trisomy 18

BackgroundIndications for extracorporeal life support (ECLS) have evolved and expanded, yet its use in trisomy 13 (T13) and trisomy 18 (T18) patients remains controversial. We reviewed the experience of the Extracorporeal Life Support Organization with ECLS in these patients to inform practice at our institution. MethodsThe Extracorporeal Life Support Organization registry was queried for all patients younger than 18 y with an International Classification of Diseases, Ninth Edition/Tenth Edition code for T13 or T18 from 2000 to 2018. Basic demographics, ECLS details, and clinical outcomes were recorded. Descriptive statistics were performed. ResultsTwenty-eight patients were identified (15 with T13; 13 with T18), representing 0.06% (28 of 46,901) of pediatric ECLS cannulations. The median weight was 3.5 kg (range, 1.4-13), and age at cannulation was 52 d (range, 0 d-6.8 y). Time on ECLS ranged from 13 to 478 h (median, 114). Cardiac defects were diagnosed in 19 (68%) patients, of which 13 (46%) underwent surgical repair. Median oxygenation index pre-ECLS was 45. Venoarterial cannulations accounted for 82% of patients, whereas 14% underwent venovenous cannulation. Overall survival to hospital discharge was 46% with 86% of patients experiencing one or more complications. There were no survivors when cannulation continued past 12 d. ConclusionsAlthough complications are frequent, the mortality rate in patients with T13 and T18 remains within the reported range for the general pediatric population. T13 and T18 alone should not be viewed as absolute contraindications to ECLS within the pediatric population but rather considered during the evaluation of a patient's potential candidacy.

Early lactate changes improve the outcome prediction for extracorporeal membrane oxygenation.

Serial lactate (clearance) data are commonly used for risk stratification in patients receiving veno-arterial extracorporeal life support (ECLS). We retrospectively analysed 855 patients who had undergone ECLS due to cardiac (n = 578) and non-cardiac (n = 277) aetiologies between 2002 and 2013 at National Taiwan University Hospital. Serial lactate (clearance) data were collected before ECLS and at 8, 16, 24, 48 and 72 h after ECLS. To investigate the impact of lactate (clearance) levels on 180-day survival, we performed linear mixed model and joint model analyses using the Bayesian approach. Among the 855 patients, 564 (65.9%) patients died within 180 days after ECLS cannulation. The joint model showed that the effect of lactate on survival was null in both the reduced model and the fully adjusted model. However, an effect of lactate clearance on survival was observed in the reduced model [estimate 0.004; 95% confidence interval (CI) 0.002-0.006] and the fully adjusted model (estimate 0.003; 95% CI 0.001-0.005). In a further secondary analysis, lactate clearance (hazard ratio 0.861; 95% CI 0.813-0.931) at 16 h after ECLS cannulation was determined to be a risk factor for mortality. According to a receiver operating characteristic curve analysis, the SAVE score combined with lactate clearance (area under curve = 0.881) showed good outcome discrimination. Incorporating lactate clearance at 16 h after ECLS cannulation into the SAVE system improved the predictive value for mortality in patients receiving ECLS.

Extracorporeal life support for phaeochromocytoma-induced cardiogenic shock: a systematic review

Phaeochromocytoma is a catecholamine-secreting tumour associated with clinical presentation ranging from paroxysmal hypertension to intractable cardiogenic shock. Extracorporeal life support, in veno-arterial mode, application in refractory acute heart dysfunction is sharply increasing worldwide. However, its clinical utility in phaeochromocytoma-induced cardiogenic shock remains still unclear. A systematic review of published reports was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement. Searches were accomplished on PubMed, Embase and Google Scholar to identify articles describing the use of extracorporeal life support in the setting of phaeochromocytoma-induced cardiogenic shock (PROSPERO: CRD42019125225). Thirty-five reports, including 62 patients supported with extracorporeal life support because of intractable phaeochromocytoma crisis, were included for the analysis. Almost all the subjects underwent peripheral cannulation for extracorporeal life support. The median duration of the mechanical circulatory support was 5 days, and most of the patients recovered normal myocardial function (left ventricular ejection fraction ⩾50%). In-hospital survival was 87%. Phaeochromocytoma was removed surgically during extracorporeal life support in 10 patients (16%), while in the remaining after haemodynamic stabilization and weaning from the mechanical support. Successful management of phaeochromocytoma-induced cardiogenic shock depends on prompt recognition and immediate treatment of shock. In this scenario, extracorporeal life support may play a significant role allowing cardiac and end-organ recovery and giving time for accurate diagnosis and specific treatment.

Development and Validation of a Life-Sized Mock Circulatory Loop of the Human Circulation for Fluid-Mechanical Studies.

Mock circulatory loops (MCLs) are usually developed for assessment of ventricular assist devices and consist of abstracted anatomical structures represented by connecting tubing pipes and controllable actuators which could mimic oscillating flow processes. However, with increasing use of short-term peripheral mechanical support (extracorporeal life support [ECLS]) and the upcoming evidence of even counteracting flow processes between the failing native circulation and ECLS, MCLs incorporating the peripheral vascular system and preserved anatomical structures are becoming more important for systematic assessment of these processes. For reproducible and standardized fluid-mechanical studies using magnetic resonance imaging, Doppler ultrasound, and computational fluid dynamics measurements, we developed a MCL of the human circulation. Silicon-based life-sized dummies of the human aorta and vena cava (vascular module) were driven by paracorporeal pneumatic assist devices. The vascular module is placed in a housing with all arterial branches merging into peripheral resistance and compliances modules, and blood-mimicking fluid returns to the heart module through the venous dummy. Compliance and resistance chambers provide for an adequate simulation of the capillary system. Extracorporeal life support cannulation can be performed in the femoral and subclavian arteries and in the femoral and jugular veins. After adjusting vessel diameters using variable Hoffmann clamps, physiologic flow rates were achieved in the supraaortic branches, the renal and mesenteric arteries, and the limb arteries with physiologic blood pressure and cardiac output (4 L/min). This MCL provides a virtually physiologic platform beyond conventional abstracted MCLs for simulation of flow interactions between the human circulation and external circulation generated by ECLS.

Medical and Surgical Management of ECLS as Bridge to Recovery and Transplantation for Pulmonary Hypertension: A Large Single Center Experience

Purpose Despite advanced targeted medical therapy, patients with pulmonary hypertension (PH) can experience gradual or sudden progression of their symptoms due to an acute insult. Application of extracorporeal life support (ECLS) for advanced PH is evolving. We examined our single-center experience using ECLS as bridge to recovery (BTR), non-transplant surgery (BTNTS), or lung transplantation (BTT) in patients with PH. Methods We conducted a retrospective analysis of all adult patients with non-WHO group 2 PH who received ECLS at New York Presbyterian - Columbia University Medical Center between 2010 and 2018. We describe clinical characteristics and our specialized approach to medical and surgical management in this cohort. Results There were 98 PH patients in the cohort (54 female; median age 48 years (IQR 32-58)). Thirty-six (36.7%) patients received ECLS with intent to BTR (including 10 BTNTS) and 62 (63.3%) to BTT, including 8 who received ECLS during or immediately after lung transplantation. In the overall cohort, 58 (59.1%) patients received VA-ECLS, including upper body Sport Model (n=13), and upper body Central Sport Model (n=7). Nine (9.2%) patents received VVA-ECLS. Thirty-two (32.7%) patients received VV-ECLS including 4 via a congenital pulmonary-systemic shunt for “VA” physiology. Serum lactate, creatinine, brain natriuretic peptide, and arterial blood gas measures improved after ECLS cannulation. Sixty-eight (70%) patients were liberated from invasive mechanical ventilation while receiving ECLS. Management of PH medications followed an intentional strategy of de-escalation for BTT and ramp down and then ramp up for non-surgical BTR. PH medications including intravenous and inhaled prostanoids, endothelin receptor antagonists, and phosphodiesterase 5 inhibitors were used most often in BTR patients and in WHO group 1 PH BTT patients. Survival to decannulation in this cohort was 85.7%; 30-day survival was 71.4%. Conclusion ECLS instituted by a specialized, multidisciplinary PH/ECLS team has a growing role in the management of advanced non-WHO group 2 PH as BTR, BTNTS, or to BTT. Careful selection of cannulation configurations, patient-specific optimization of PH medical therapies, and avoidance of endotracheal intubation may be an effective strategy in managing these complex patients.

Right subclavian to brachial artery dissection after neck cannulation for extracorporeal life support in a newborn

Abstract We present a patient with a distal arterial dissection after extracorporeal life support (ECLS) cannula placement. A preterm boy with severe pulmonary hypertension, secondary to probable premature closure of the ductus arteriosus, was placed on venoarterial extracorporeal life support utilizing his right internal jugular vein and his right carotid artery. Post-procedure echocardiogram (ECHO) confirmed correct placement, however after the child was routinely repositioned, the arterial cannula was noted to have advanced into his right subclavian artery. The cannula was repositioned back to the innominate artery, but a bilateral duplex revealed an arterial dissection extending from the right distal subclavian artery to the mid brachial artery. Serial duplex exams during ECLS revealed no propagation of the dissection. At decannulation no repair was performed and subsequent duplex exams show stable flow with no distal obstruction.

Local and Lower Limb Complications during and after Femoral Cannulation for Extracorporeal Life Support.

The extracorporeal life support system (ECLS) system is a lifesaving option for patients in pulmonary and/or cardiac failure. We reviewed our data on local complications in the leg and groin during and after ECLS explantation. Patients were included when an ECLS was cannulated in the groin and the ECLS was successfully weaned and explanted. Data were collected retrospectively in patients from January 2013 to January 2016. In this study, 90 patients were included; 39 (43%) ECLS were implanted with surgical cut down and 51 (57%) ECLS were implanted percutaneously. Most patients needed ECLS support following cardiac surgery: cut down: 25 (64%) versus percutaneous: 28 (55%) (p = 0.40). A distal leg perfusion cannula was implanted simultaneously in 61 (68%) patients (cut down: 25 [64%] vs. percutaneous: 36 [71%], p = 0.36). Distal leg ischemia was diagnosed in a total of 10 (11%) patients (cut down: 2 [5%] vs. percutaneous: 8 [16%], p = 0.18). Of those 10 patients, 5 patients had leg ischemia despite a distal leg perfusion cannula in place (cut down: 1 [3%] vs. percutaneous: 4 [8%], p = 0.38). Revascularization was successfully achieved in all patients and no amputations had to be performed. Similar rates of wound healing disorders were observed in both groups: cut down: 11 (28%) versus percutaneous: 10 (20%) patients (p = 0.45). Surgical and percutaneous implantation and explantation of ECLS are safe and feasible with comparable complication rates, including wound healing disorders. We recommend that a lower limb perfusion cannula should be placed to prevent leg ischemia. Surgical cut-down placement of the distal leg perfusion cannula may reduce the incidence of distal leg ischemia compared with percutaneous distal leg cannula implantation. Correct placement of the cannula should be controlled.

Novel ECMO surgical cannulation simulators

Simulation training is increasingly being used to provide clinical care providers with experience and competence in high-risk procedures that occur infrequently. Implementation of standardized extracorporeal life support (ECLS) simulation training improves multidisciplinary team processes and increases efficiency of establishing ECLS. The initiation of ECLS is a highly complex process that requires technical proficiency of the surgeon and frequently depends on advanced crisis-management skills. Human performance simulation systems can be designed to simulate complex surgical procedures and used to teach and assess technical skills and refine team management protocols. Furthermore, high-fidelity simulators may enhance technical competency and improve patient safety. The use of ECLS cannulation simulation has been shown to improve proficiency of surgical cannulation.1 However, advanced surgical skills simulators are generally expensive and require extensive setup time.2 The use of commercially available simulation systems that cost >$500 USD per use represents a significant financial burden for many centers that are establishing an ECLS program. Affordable ( < $10 USD per use), silicone-based ECLS cannulation simulators can be created using commercial available materials. Custom ECLS cannulation simulators may be designed to fulfill specific educational and quality improvement requirements in unique hospital settings. High-fidelity simulation models may be used to accurately recreate anatomic structures. When integrated into a comprehensive ECLS simulation program, cannulation simulators create a more realistic learning environment that more accurately represents clinical scenarios encountered in the clinical management of ECLS patients, including cannula malpositioning events, bleeding, air entrainment, and hypovolemia. In addition, ECLS cannulation simulators can be used to teach and reinforce proper techniques in a standardized manner. Commercially available, silicone-based materials may be combined to reproduce layers of skin, subcutaneous tissue, blood vessels, and boney. Percutaneous models utilize similar materials but require additional processing to render ECLS cannulation models ultrasound compatible. Cannulation simulators may be integrated with low-cost compliance chambers and tubing to reproduce circulatory physiology after initiating ECLS. Although each cannulation simulator may be used only once, the raw materials for custom-made simulators cost less than $10 USD each. This low cost for production allows centers to use them frequently and incorporate them into existing skills-based ECLS training programs. Percutaneous cannulation simulators that are designed to reproduce the cervical cannulation with dual-lumen veno-venous ECLS cannulae are being developed by our team. These novel simulators will enable users to perform ultrasound-guided percutaneous reproduce cannulation using standard dual-lumen cannulae and echocardiography. This system will facilitate communication between proceduralists and echocardiographers.

Percutaneous Cannulation for Extracorporeal Life Support

Extracorporeal life-support systems are valuable tools to treat patients with acute cardiopulmonary failure in intensive care facilities, and are highly suitable for the interhospital transfer of critically ill patients to specialized centers. This article reviews the cannulation strategies and associated vascular complications in our institution. Between January 2004 and December 2009, 464 extracorporeal life-support systems were implanted via percutaneous cannulation at our institution. The type and incidence of adverse events related to the percutaneous access to femoral, subclavian vessels and the jugular vein were retrospectively analyzed. The primary focus was on bleeding and limb ischemia. 464 patients (340 male, 124 female) with isolated pulmonary or combined cardiopulmonary failure were connected to extracorporeal gas exchange systems. Most patients (n = 196) were connected to a PECLA system; 158 patients to a veno-arterial ECMO. Use of a veno-venous ECMO system was necessary in 110 cases. Thirty-two patients (6.9 %) suffered bleeding complications after cannula insertion, predominantly after PECLA placement (3.9 %). After implantation, limb ischemia developed in 15 cases (3.2 %), mostly in the veno-arterial ECMO group (n = 13). Demographic data and cannula size show no significant difference between patient groups with and without ischemic complications ( P = 0.57). A prophylactic fasciotomy was performed in the 15 cases with limb ischemia. Survival was independent of ischemic (leg) complications. With proper vessel visualization, exposure and cannulation, and accurate cannula placement, optimal flows and minimal complication rates can be achieved, rendering percutaneous extracorporeal life support a safe procedure.

Rapid peripheral arterial cannulation for extracorporeal life support with unimpaired distal perfusion

Rapid peripheral arterial cannulation for extracorporeal life support with unimpaired distal perfusion

Aortic Dissection in a Neonate Associated With Arterial Cannulation for Extracorporeal Life Support

Aortic Dissection in a Neonate Associated With Arterial Cannulation for Extracorporeal Life Support

Aortic Dissection in a Neonate Associated With Arterial Cannulation for Extracorporeal Life Support

The purpose of this paper is to describe the authors' approach to the diagnosis and treatment of aortic intimal dissection encountered as a complication of the arterial cannulation procedure employed routinely during neonatal venoarterial ECMO. A case report is provided. Recognition of this entity clinically was based on diminished pulses in the lower extremities with dampening of an umbilical arterial catheter transduced pressure wave form one day after decannulation from ECMO. Confirmation was achieved using a phased array echocardiographic Doppler system (ECHO). Successful surgical repair was achieved under deep hypothermic circulatory arrest on cardiopulmonary bypass, with partial resection of the affected aorta, and with sutures placed through the intimal flap and the aortic wall. Aortic continuity was established by end-to-end anastamosis posteriorly, and the aortic arch was reconstructed anteriorly with an aortic homograft. To the author's knowledge, this is the first case of this problem being identified and treated in an ECMO treated neonate.