Acute Limb Ischemia In Patients On Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support: A Ten-Year Single-Center Experience
Besma J. Nejim, MBChB MPH1, Rachael Snow, MD1, Marvin Chau, BS2, Surav Sakya, BS1, Maria Castello Ramirez, MD1, Tanya Flohr, MD1, Christoph Brehm, MD1, Faisal Aziz, MD1.
1Penn State Hershey Medical Center, Hershey, PA, USA, 2Penn State University, Hershey, PA, USA.
Objectives: VA-ECMO has been increasingly utilized as a life-saving modality in patients with cardiopulmonary compromise. Acute limb ischemia (ALI) has been reported when femoral artery used as access and it was associated with higher mortality in patients on ECMO. However, prior studies were limited by small sample size and the lack of long-term follow-up. We aim to investigate the predictors of ALI in ECMO and the effect of ALI on long-term mortality.
Methods: Retrospective institutional chart review was performed. Patients who underwent VA-ECMO (Jan/2008-Jan/2018) were identified. Primary outcomes were ALI and 4-year mortality. Logistic regression analysis was used to investigate the predictors of ALI. Survival analysis methods were used to examine 4-year mortality.
Results: A total of 377 patients were included. Vascular complications took place in 149 (39.5%) patients. The majority was ALI (107, 75.4%). Eleven patients had limb loss. ALI patients were younger (mean age: 50.2±15.9 vs 54.1±15.5; p=.03), more likely to have history of PAD (7.6%vs 3.0%; p=.047), less likely to be on aspirin (40.2% vs 54.4%; p=.013), and more likely to be on vasopressors (97.1% vs 88.0%; p=.007). Arterial cannula size was not associated with ALI so as the concurrent use of ventricular offloading devices (intra-aortic balloon pump or Impella). The use of distal perfusion catheter (DPC) was not protective against ALI in this cohort. However, DPC was associated with less likelihood to require vascular intervention (20.1% vs 32.0%; p=.009). In adjusted analysis, aspirin use was protective against ALI [adjusted odds ratios (aOR) 95%CI: 0.52(0.30-0.90); p=.018]. The only predictor of ALI was the use of vasopressors [aOR(95%CI): 6.8 (1.5-30.4); p=.012]. For those who were successfully decannulated, four-year survival was 65.1% in patients without ALI vs 46.8% in ALI (p=0.044) (figure). After adjusting for potential risk factors, 4-year mortality hazard was significantly higher in patients with ALI [HR: 1.80(1.04-3.12); p=.035].
Conclusions: Patients requiring ECMO are critically ill. The development of acute limb ischemia is detrimental in this population. This effect extends beyond the acute period. ALI increased 4-year mortality risk by 80%. Use of DPC did not protect against ALI but it was associated with less vascular interventions. 
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