Complications of axillary artery injury from Extra-corporal Membrane Oxygenation (ECMO) cannulation
Min Li Xu, Aditya Safaya, Sateesh Babu, Igor Laskowski.
Westchester Medical Center, Valhalla, NY, USA.
Objective: Extra-Corporeal Membrane Oxygenation (ECMO) is an important tool for management of patients with severe cardiac and pulmonary dysfunction. However, little is known about the management of complications arising from ECMO access involving the axillary artery. We present our experience with ECMO related axillary artery injuries. Methods: From June 2016 to August 2017 a total of 80 ECMO procedures were performed. 7 patients with ECMO-related complications were evaluated. Two patients were excluded-one with femoral artery bleeding and one with axillary area abscess who declined surgical management. All remaining patients underwent axillary artery cannulation and required surgical intervention due to ECMO related complications. Patients were evaluated by the type of presentation, surgical management and early outcomes. Results: In all ECMO cases, 8mm dacron conduit was anastomosed end-to-side to the axillary artery for cannula placement. Upon ECMO discontinuation, the dacron conduit was removed with its remnant oversewn as a patch over the arteriotomy site. 5 patients (8.75%) with a total of 7 arterial cannulations performed in the axillary arteries experienced vascular access complications. Initial presentation included overt bleeding with arterial blow out (3 cases), contained rupture with pseudoaneurysm formation (1 case) or limb ischemia (1 case). Two patients had life-threatening hemodynamic instability. SIRS criteria and bacteremia was documented in two patients. Four patients developed infections at their axillary artery site. Positive wound and blood cultures grew Staphylococcus, Klebsiella, Pseudomonas, Enterococcus, and Candida species. In all cases, axillary revascularization was performed with individualized patient specific approach: one axillary artery thrombectomy and repair with bovine pericardium patch, one carotid to brachial artery bypass with cadaveric greater saphenous vein (GSV), one axillary to brachial artery bypass with basilic vein, and three subclavian to brachial artery bypass with prosthetic graft, autologous and cadaveric GSV. Infected arterial segment were debrided in all but one case of arterial patch. Six wounds were left open, one was closed and required repeat operative debridement. Successful re-vascularization with distal limb perfusion and eventual wound healing was achieved in all patients. Conclusion: In the era of increasing ECMO use, a greater incidence of vascular access complications can be anticipated. We emphasize early recognition of this problem, prompt re-vascularization with delayed wound closure in all cases and complete prosthetic graft removal upon ECMO discontinuation.
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