Original articleLimb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem☆
Introduction
Extracorporeal Life Support Organization (ELSO) Registry data confirm that the annual number of pediatric patients, 1 to 18 years old, being supported by extracorporeal membrane oxygenation (ECMO) is increasing [1]. This is true for both respiratory and cardiac indications. Most of these patients are being supported via venoarterial (VA) ECMO. According to recent data, more than 50% of patients are placed onto VA ECMO for refractory respiratory failure. This number increases to nearly 100% of patients supported for cardiac indications.
Venoarterial ECMO requires cannulation of a large artery to deliver oxygenated blood to the patient. Traditionally, the carotid artery is used as the site of insertion for the arterial cannula. However, this technique requires distal ligation of the carotid artery, which interrupts blood flow to the areas of the brain supplied by that vessel. If collateral circulation is not sufficient, the patient may be placed at risk for an immediate or future stroke. Studies of neonatal ECMO survivors have shown a comparable incidence of major neurologic disability after carotid ligation to critically ill neonates not requiring ECMO [2]. However, it is not clear at what age the brain loses its ability to adapt to ligation of the carotid artery. Pediatric aged patients may be at a higher risk of neurologic injury if the carotid artery is used.
To minimize the potential neurologic effects of carotid artery ligation, the common femoral artery (CFA) has been used as the site of arterial cannulation for ECMO. The annual incidence of pediatric patients supported on VA ECMO via the CFA is increasing as well [1]. Although this decreases the neurologic complications of arterial cannula placement, it presents its own unique risks. The arterial cannula may obstruct forward flow to the limb, placing it at risk for ischemia and possible limb loss [3]. The exact incidence of limb ischemia is not known because it is not routinely recorded in the ELSO Registry. In 2 small series, the incidence of ischemia associated with VA ECMO via the CFA ranged from 30% to 50% [4], [5].
To relieve limb ischemia, distal perfusion catheters (DPCs), endovascular therapy, and femoral-to-femoral bypass grafts have been proposed [3], [6], [7]. However, many of these techniques are instituted after the development of ischemia. A delay in initiation of therapy may lead to an irreversibly injured limb. This led us to inquire if there were any precannulation variables that could accurately predict the development of significant limb ischemia. We present a single institution's experience with CFA cannulation for VA ECMO and examine precannulation variables that were associated with limb ischemia.
Section snippets
Methods
We reviewed all pediatric patients who were supported by VA ECMO via CFA cannulation from January 2000 to February 2010 at Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY. Study approval was granted by the Columbia University Institutional Review Board (IRB-AAAF0896) (New York, NY).
Cannula size was determined by selecting the smallest arterial cannula that could deliver the maximal required flow. The maximal flow for each patient was determined by multiplying the body
Results
During our study period, we identified 21 patients who were cannulated via the common femoral artery for VA ECMO. The age of the patients ranged from 2 to 22 years. Of the 21 patients cannulated via the common femoral artery, 19 were placed percutaneously and 2 via open cut down. In 6 percutaneous cases, placement occurred in the cardiac catheterization laboratory using fluoroscopy as these patients required a further cardiac intervention. In the remaining 13 cases, anatomical landmarks for the
Discussion
Limb ischemia is a significant problem as there was a 52% incidence in our study. The true incidence may be underrepresented as there was a 60% mortality in the no-ischemia group. It is possible that these patients may have gone on to develop ischemia during their ECMO course.
The overall incidence of ischemia is not known. This is because the ELSO Registry does not routinely record limb ischemia as a complication. Currently, most of published studies discussing limb ischemia after VA ECMO are
Acknowledgments
Peter Rycus, MPH, Extracorporeal Life Support Organization.
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2020, Journal of Pediatric SurgeryCitation Excerpt :Some surgeons do repair the carotid artery after decannulation [22], but this practice was outside the scope of this survey. Alternatively, when the femoral artery is used, the sequela of limb ischemia is certainly significant, and the data are not yet conclusive [19]. At this time practice patterns remain largely center-specific.
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Presented at the 2010 CNMC ECMO Symposium, Keystone, Colo.