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Updated Assessment Of Vascular Complications And Vascular Surgery Interventions In Patients Undergoing Extracorporeal Membrane Oxygenation
Claire M. Motyl, MD, Joseph R. Chitwood, MD, Cameron T. Derryberry, Joshua Tsai, Erik J. Orozco Hernandez, MD, Benjamin J. Pearce, MD.
University of Alabama at Birmingham, Birmingham, AL, USA.
OBJECTIVE: Updated assessment of the clinical impact of vascular complications affecting patients undergoing extracorporeal membrane oxygenation (ECMO) at a high-volume academic center, and description of associated changes in clinical practice.
METHODS: Retrospective single-center review of patients cannulated for peripheral VA ECMO via femoral or axillary access during the period 2020-2024. Primary outcomes were development of any vascular complication including acute limb ischemia (ALI), cannula site infection (CSI), pseudoaneurysm or clinically significant hematoma or hemorrhage, need for vascular surgery intervention, and overall mortality.
RESULTS: 258 patients were included. Overall vascular complication rate was 26% (ALI 13.2%, CSI 7.8%, hematoma 10.1%, pseudoaneurysm 10.1%, fasciotomy 6.2%, amputation 1.2%; not mutually exclusive). Vascular Surgery intervention was performed in 17.8% of all patients. Younger age, female sex, and higher BMI were associated with development of vascular complications. Development of vascular complications was not associated with overall mortality. Distal perfusion cannulas (DPC) were placed in 78% of patients; delayed DPC placement demonstrated a trend towards vascular complications (p=0.06). 1 of 8 patients who underwent axillary cannulation developed acute limb ischemia requiring upper extremity amputation. When performed, arterial reconstructions included primary repair or patch angioplasty in 69.2% (generally including thromboembolectomy), bypass grafting in 25.6%, and stent-grafting in 2 patients. Of cannula site infections, 65% were gram-negative organisms. 80% of initial bypasses were temporizing prosthetic or cryopreserved conduits, with only 2 definitive reconstructions performed at the index operation using autologous conduits.
CONCLUSIONS: Vascular complications associated with ECMO cannulation remain prevalent and often require Vascular Surgery intervention. The current data reflect improvement in overall complication and intervention rates relative previously published institutional data. Our management of cannula site arterial infections, in particular, has evolved in response to growing institutional experience, and emphasizes temporizing repair followed by sterilization prior to definitive management. Interdisciplinary collaboration for early identification of and intervention for vascular complications is imperative to continue reductions in morbidity associated with vascular complications in patients on ECMO.
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