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Association Of Duplex Ultrasound Peak Ankle Velocities With Ischemic Complications And Mortality In Patients On Peripheral VA-ECMO
Joshua T. Geiger, MD1, Mario M. Matabele, MD
1, Lehane J. Daniel, MD
2, Anthony Pohahau, BS
3, Blake E. Murphy, MD
4, Joel Kruger, MD, MPH
5, Deepika P. Kamineni, BS
4, Pedro Galvan, BS
4, Yang Gu, MD
6, Leo Daab, MD
3, Sherene Shalhub, MD, MPH
3, Katherine L. Wood, MD
7, R. Eugene Zierler, MD
4, Michael Stoner, MD
1, Karina Newhall, MD, MS
1.
1Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY, USA,
2Division of Vascular Surgery, Washington University in St. Louis, St. Louis, MO, USA,
3Division of Vascular and Endovascular Surgery, Oregon Health & Science University, Portland, OR, USA,
4Division of Vascular Surgery, University of Washington, Seattle, WA, USA,
5Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA,
6Division of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA,
7Division of Cardiac Surgery, University of California-Irvine, Irvine, CA, USA.
OBJECTIVES: Peripheral VA-ECMO can be lifesaving but carries vascular complication risks that may increase risk of mortality. Few studies have assessed duplex ultrasound velocities to predict ischemia or mortality. The objective of this study is to evaluate ankle peak systolic velocity (APSV) via duplex ultrasound in patients supported on peripheral VA-ECMO and its relationship to ischemic complications and mortality.
METHODS: This multi-institutional retrospective review included patients undergoing peripheral VA-ECMO between January 2013 and July 2023 with all available duplex ultrasound peak systolic velocities. APSV was defined as the max peak systolic velocity of the anterior tibial, posterior tibial, and peroneal arteries near the ankle. Primary outcomes were mortality and ischemic complications requiring intervention (downsizing the arterial cannula, repositioning the arterial cannula, placement of a distal reperfusion catheter, or an ischemia-related surgical intervention) while supported on peripheral VA-ECMO.
RESULTS: The final cohort included 197 VA-ECMO patients with ultrasound data from three institutions. The mean age was 54.1 ± 14.6 years and 73.1% of patients were white. Mortality on ECMO was 60.9% and 38.6% of patients sustained ischemic complications. Reduced APSV was associated with ischemic complications (OR 0.76, 0.57-1.00, p = 0.047) and mortality while on ECMO (OR 0.83, 0.70-0.99, p = 0.042). Multivariable mixed effect logistic regression identified same-sided arterial/venous cannula (OR 2.3, 0.99-5.38. p=0.054) and increased ECMO flow at initiation (OR 1.53, 1.00-2.34, p=0.048) to be significantly associated with ischemic complications. Arterial cannula size and use of a distal perfusion catheter at initial ECMO cannulation were not associated with ischemic complications. Multivariable mixed effect logistic regression also identified an association between age (OR 1.02-1.07, p<0.001) and diabetes (OR 0.46, 0.22-0.93, p=0.032) with mortality while on ECMO (Figure 1).
CONCLUSIONS: APSV is associated with ischemic complications and mortality while supported on peripheral VA-ECMO. Opposite-side placement of venous/arterial sheaths and reduced ECMO flow at initiation are protective against ischemic complications. Increasing age and diabetes are associated with increased mortality. Ischemic complications were not associated with mortality during ECMO support. These data demonstrate that ultrasonographic findings may help predict both ischemic complications and mortality in patients with peripherally cannulated VA-ECMO.
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