Critical Limb Ischemia in Patients, Undergoing Femoral Cannulation for Venoarterial Extracorporeal Membrane Oxygenation: Is a Distal Limb Perfusion a Mandatory Approach?

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is a well-established tool in the care of severe refractory cardiac and respiratory failure. The application of this support may serve as a bridge to transplant, recovery or to implantation of a ventricular assist device. VA-ECMO support can be administered through an open surgical access via the common femoral or axillary artery, or an percutaneous approach using Seldinger technique. Both techniques may obstruct the blood-flow to the lower limb and may cause a significant ischemia with possible limb loss. Malperfusion of the distal limb can be avoided using an ipsilateral distal limb perfusion (DLP), which may be established by adding a single-lumen catheter during VA-ECMO treatment to overcome the obstruction. Aim of the present study is to determine significant risk factors of the open versus the percutaneous femoral VA-ECMO installation for the development of distal limb ischemia.

Methods: Between January 2012 and September 2015, 489 patients received VA-ECMO support at our institution. 307 (204 male, 103 female) patients with femoral cannulation were included in the analysis. The cohort was distinguished by the presence (group A; n = 237) or absence (group B; n = 70) of a DLP during peripheral VA-ECMO treatment. Furthermore a risk factor analysis for the development of a distal limb ischemia was performed.

Results: The main indications for VA-ECMO therapy were a low-cardiac-output-syndrome (53%) and failed weaning of extracorporal circulation (23%). A total of 23 patients (7.49%) under VA-ECMO support developed severe distal limb malperfusion (3.38% in group A versus 21.42% in group B). Preemptive installation of DLP extended the intervention-free intervals to 7.8 ± 19.3 days in group A and 6.3 ± 12.5 in group B. A missing DLP (p = 0.001) was identified as a main risk factor for critical limb ischemia. Other comorbidities such as arterial occlusion disease (p = 0.738) were not statistically significantly associated. Surgical intervention due to vascular complications after ECMO explantation was needed in 14 cases (4.22% in group A) (5.71% in group B).

Conclusion: We were able to identify the absence of DLP as an independent risk factor for the development of critical distal limb ischemia during femoral VA-ECMO treatment. The application of a DLP should be evaluated as a mandatory procedure in the context of femoral VA-ECMO treatment regardless of the implantation technique.

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