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

doi:10.1016/j.jpedsurg.2010.07.005

Journal of Pediatric Surgery

Volume 45, Issue 11, November 2010, Pages 2136-2140

https://doi.org/10.1016/j.jpedsurg.2010.07.005 Get rights and content

Abstract

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 χ² 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.

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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Patients 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.
We 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.
Of 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.
The 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.
Extremity fasciotomy for patients on extracorporeal membrane oxygenation is independently associated with inpatient mortality
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Extracorporeal membrane oxygenation (ECMO) maintains end-organ perfusion in critically ill patients with cardiac or respiratory failure; however, ECMO cannulation in the extremities has been associated with significant limb ischemia and risk of compartment syndrome. Current literature on ECMO and fasciotomies is limited to small single-center retrospective studies. This study aimed to (1) compare the incidence of postoperative outcomes and mortality in patients undergoing fasciotomy while on ECMO to those of non-fasciotomy ECMO patients, and (2) assess the difference in adjusted mortality risk between the two groups.
We hypothesized that patients undergoing fasciotomy while on ECMO would have significantly higher odds of in-hospital mortality than non-fasciotomy ECMO patients after adjustment for perioperative variables.
We conducted a retrospective review of NIS from January 1st, 2012-September 30, 2015 for all hospitalizations involving ECMO and stratified them into two cohorts based on whether they underwent fasciotomy after ECMO. Patient baseline characteristics, in-hospital procedures, and postoperative outcomes were compared between the two cohorts. Logistic regression was used to assess in-hospital mortality risk between the two cohorts adjusting for age, sex, Elixhauser score, and perioperative procedures and non-fasciotomy perioperative morbidity.
There were 7,085 estimated eligible discharges between 2012 and 2015 identified, 149 (2.1%) of which underwent fasciotomy following ECMO. One hundred and thirteen of the 149 hospitalizations (77%) in the fasciotomy cohort resulted in in-hospital mortality, compared to 3,805 of the 6,936 (55%) in the non-fasciotomy cohort. There were no differences in rates of transfusion (p = 0.290), length of stay (p = 0.282), or discharge disposition (p = 0.126) between the two cohorts. In the logistic regression model, the fasciotomy cohort had a higher odds of in-hospital mortality than non-fasciotomy cohort (OR, 2.5; 95% CI, 1.1–5.6).
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: No studies exist comparing various femoral artery cannula sizes in children on ECMO. We hypothesize that smaller arterial cannulas provide adequate flow in children while decreasing vascular complications.
: We performed a retrospective review of the ELSO database from 2012–2017. We included children undergoing femoral venoarterial ECMO between ages 12 and 18 years and weighing more than 30 kg. Arterial cannula sizes were grouped as: 15-16Fr, 17–18Fr, 19–20Fr and ≥21Fr. Arterial pump flow, bleeding complications, limb ischemia, and mechanical complications were compared by cannula size. Distal perfusion catheter and percutaneous placement were also compared for complications.
: A total of 429 patients were included with 28.2% 15–16Fr, 32.2% 17–18Fr, 22.8% 19–20Fr, and 16.8% ≥ 21Fr arterial femoral cannulas. Median age was lower in the 15–16Fr group compared to the largest cannula group (14.7 years vs 15.5 years, p < 0.01). The overall mean arterial flow was 57.4 +/- 17.0 mL/kg/min with no difference in mean arterial flow rates among the cannula size groups (p = 0.85). There were no significant differences in all complications, bleeding or mechanical complications by arterial cannula size group. However, there was an increased risk of limb ischemia in the ≥21Fr group compared to the 15–16Fr group (OR 4.38, 95% CI 1.24–15.43; p = 0.02). Distal perfusion catheter was shown to increase the risk of mechanical complications (OR 1.78; 95% CI 1.03–3.07; p = 0.04) but did not make a statistically significant difference in limb ischemia (OR 0.37; 95% CI 0.12–1.11; p = 0.07).
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Citation 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.

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Original articleLimb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem☆

Abstract

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

J Pediatr

J Pediatr Surg

Br J Anaesth

Annals Thorac Surg

J Thorac Cardiovas Surg

ECMO Registry of the Extracorporeal Life Support Organization (ELSO)

Long-term survival with use of percutaneous extracorporeal life support in patients presenting with acute myocardial infarction and cardiovascular collapse

ASAIO J

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