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Vascular Complications and Use of a Distal Perfusion Cannula in Femorally Cannulated Patients on Extracorporeal Membrane Oxygenation
David N. Ranney, MD, Ehsan Benrashid, MD, James Meza, MD, Jeffrey Keenan, MD, Desiree Bonadonna, MPS, CPP, Leila Mureebe, MD, Mitchell W. Cox, MD, Mani Daneshmand, MD.
Duke University, Durham, NC, USA.
OBJECTIVES:
As the indications for extracorporeal membrane oxygenation (ECMO) continue to expand, it is theorized that femoral veno-arterial (VA) cannulation results in a higher incidence of vascular complications and limb malperfusion. Placement of a distal perfusion cannula (DPC) at the time of ECMO deployment is a frequent protective strategy, however, its benefit remains unclear and there exists no level one evidence in favor of its use. The objective of this study was to compare the incidence of vascular complications and patient outcomes in regard to the early use of a DPC.
METHODS:
A single-institution, retrospective analysis was performed on patients undergoing VA ECMO cannulation between June 2009 and April 2015. Demographics, details of ECMO deployment, and clinical events and outcomes were acquired from the medical record. Vascular complications were defined as fasciotomy, amputation, conversion to central cannulation after clinical determination of limb ischemia, delayed placement of DPC for limb ischemia, thrombectomy, cannula site exploration due to bleeding, and non-routine arteriorrhaphy due to vessel injury. Descriptive statistics were performed to compare those who did and did not receive a DPC at the time of deployment.
RESULTS:
Eighty of 132 patients receiving VA ECMO were cannulated via the femoral artery (60.6%). Of these, 14 received a DPC at deployment (17.5%). Demographics, indications for ECMO, and cardiovascular history and risk factors were not significantly different between comparison groups. Mean arterial cannula size was 17 Fr in both groups. Vascular complications occurred in 2 of 14 patients with initial DPC (14.3%) compared to 21 of 66 without initial DPC (31.8%) (p=0.188). Zero patients required fasciotomy or amputation. The most common intervention was conversion to central cannulation due to limb ischemia which 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.
CONCLUSIONS:
The use of a DPC has been argued to be protective of vascular and ischemic limb complications. Although not statistically significant, this single-center retrospective study suggests a lower incidence of these complications with placement of a DPC at the time of ECMO cannulation. Randomization of patients to the initial use of a DPC may further characterize its efficacy and may assist in the development of treatment guidelines.
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