Novel cannulation strategy with a bidirectional cannula for distal limb perfusion during peripheral veno-arterial extracorporeal life support: A preliminary,single-centre study
Restricted accessResearch articleFirst published online May, 2023
Novel cannulation strategy with a bidirectional cannula for distal limb perfusion during peripheral veno-arterial extracorporeal life support: A preliminary,single-centre study
Limb ischemia is a severe complication of peripheral veno-arterial extracorporeal life support (V-A ECLS). Several techniques have been developed to prevent this, but it remains a major and frequent adverse event (incidence: 10–30%). In 2019, a new cannula with bidirectional flow (retrograde towards the heart and antegrade towards the distal limb) has been introduced. A single-centre experience with this cannula in patients undergoing peripheral V-A ECLS is herewith reported.
Methods
This prospective observational study included adults (≥18 years) undergoing V-A ECLS from January 2021 to October 2022 with the use of a bidirectional femoral artery cannula. Primary outcome was limb ischemia requiring intervention during cardio-circulatory support. Secondary outcomes were compartment syndrome, limb amputation, cannulation site bleeding, need for other surgical intervention due to cannula related complications, duplex ultrasound parameters from the femoral vessels, and in-hospital survival.
Results
Twenty-two consecutive patients were included. During extracorporeal life support (ECLS) support, limb ischemia requiring intervention occurred in one patient (4.5%) and no patients developed a compartment syndrome, or required a fasciotomy or amputation. Significant bleeding was reported in two patients (9%) due to slight cannula dislodgement, easily solved with cannula repositioning. In-hospital survival was 63.6%.
Conclusions
The bidirectional cannula is associated with a low risk for limb ischemia-related complications compared to current literature, and apparently represents a safe alternative to dedicated distal perfusion cannula. Further studies are warranted to confirm these preliminary findings.
JuoYYSkanckeMSanaihaY, et al.Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs2017; 41: E263–e273. DOI: 10.1111/aor.12942.
2.
JiaDYangIXLingRR, et al.Vascular complications of extracorporeal membrane oxygenation: a systematic review and meta-regression analysis. Crit Care Med2020; 48: e1269–e1277. DOI: 10.1097/CCM.0000000000004688.
3.
YangFHouDWangJ, et al.Vascular complications in adult postcardiotomy cardiogenic shock patients receiving venoarterial extracorporeal membrane oxygenation. Ann Intensive Care2018; 8: 72. DOI: 10.1186/s13613-018-0417-3.
4.
BonicoliniEMartucciGSimonsJ, et al.Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment. Crit Care2019; 23: 266–266. DOI: 10.1186/s13054-019-2541-3.
LorussoRShekarKMacLarenG, et al.ELSO interim guidelines for venoarterial extracorporeal membrane oxygenation in adult cardiac patients. ASAIO J2021; 67: 827–844.
7.
ChristensenJIpsenTDohertyP, et al.Physical and social factors determining quality of life for veterans with lower-limb amputation(s): a systematic review. Disabil Rehabil2016; 38: 2345–2353. DOI: 10.3109/09638288.2015.1129446.
8.
GrzebieńAChabowskiMMalinowskiM, et al.Analysis of selected factors determining quality of life in patients after lower limb amputation- a review article. Pol Przegl Chir2017; 89: 57–61. DOI: 10.5604/01.3001.0009.8980.
9.
AvalliLSangalliFMigliariM, et al.Early vascular complications after percutaneous cannulation for extracorporeal membrane oxygenation for cardiac assist. Minerva Anestesiol2016; 82: 36–43.
10.
AzizFBrehmCEEl-BanyosyA, et al.Arterial complications in patients undergoing extracorporeal membrane oxygenation via femoral cannulation. Ann Vasc Surg2014; 28: 178–183. DOI: 10.1016/j.avsg.2013.03.011.
11.
BisdasTBeutelGWarneckeG, et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. Ann Thorac Surg2011; 92: 626–631. DOI: 10.1016/j.athoracsur.2011.02.018.
12.
FoleyPJMorrisRJWooEY, et al.Limb ischemia during femoral cannulation for cardiopulmonary support. J Vasc Surg2010; 52: 850–853. DOI: 10.1016/j.jvs.2010.05.012.
13.
LambKMDiMuzioPJJohnsonA, et al.Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation. J Vasc Surg2017; 65: 1074–1079. DOI: 10.1016/j.jvs.2016.10.059.
14.
MaRWLHuilgolRLGrangerE, et al.Does a distal perfusion cannula reduce ischaemic complications of extracorporeal membrane oxygenation?ANZ J Surg2016; 86: 1002–1006. DOI: 10.1111/ans.13441.
15.
MohitePNFatullayevJMaunzO, et al.Distal limb perfusion: Achilles’ heel in peripheral venoarterial extracorporeal membrane oxygenation. Artif Organs2014; 38: 940–944. DOI: 10.1111/aor.12314.
16.
PapadopoulosNMarinosSEl-Sayed AhmadA, et al.Risk factors associated with adverse outcome following extracorporeal life support: analysis from 360 consecutive patients. Perfusion2015; 30: 284–290. DOI: 10.1177/0267659114542458.
17.
ParkBWLeeSRLeeMH, et al.Short stature is associated with the development of lower limb ischaemia during extracorporeal life support. Perfusion2018; 33: 383–389. DOI: 10.1177/0267659118755273.
18.
SpurlockDJToomasianJMRomanoMA, et al.A simple technique to prevent limb ischemia during veno-arterial ECMO using the femoral artery: the posterior tibial approach. Perfusion2012; 27: 141–145. DOI: 10.1177/0267659111430760.
19.
StubDBernardSPellegrinoV, et al.Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation2015; 86: 88–94. DOI: 10.1016/j.resuscitation.2014.09.010.
20.
TrubyLMundyLKalesanB, et al.Contemporary outcomes of venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock at a large tertiary care center. Asaio J2015; 61: 403–409. DOI: 10.1097/mat.0000000000000225.
21.
VallabhajosyulaPKramerMLazarS, et al.Lower-extremity complications with femoral extracorporeal life support. J Thorac Cardiovasc Surg2016; 151: 1738–1744. DOI: 10.1016/j.jtcvs.2015.11.044.
22.
WernlyJADietlCATabeCE, et al.Extracorporeal membrane oxygenation support improves survival of patients with Hantavirus cardiopulmonary syndrome refractory to medical treatment. Eur J Cardiothorac Surg2011; 40: 1334–1340. DOI: 10.1016/j.ejcts.2011.01.089.
23.
WongJKSmithTNPitcherHT, et al.Cerebral and lower limb near-infrared spectroscopy in adults on extracorporeal membrane oxygenation. Artif Organs2012; 36: 659–667. DOI: 10.1111/j.1525-1594.2012.01496.x.
24.
YeoHJYoonSHJeonD, et al.The utility of preemptive distal perfusion cannulation during peripheral venoarterial extracorporeal membrane oxygenation support. J Interv Cardiol2016; 29: 431–436. DOI: 10.1111/joic.12309.
25.
GunaydinSBabarogluSBudakAB, et al.Comparative clinical efficacy of novel bidirectional cannula in cardiac surgery via peripheral cannulation for cardiopulmonary bypass. Perfusion2023; 38: 44–50. DOI: 10.1177/02676591211033945.
26.
MacLarenGPeekGLorussoR, et al.Extracorporeal life support: the ELSO red book. 6th edition. Ann Arbor, MI: Extracorporeal Life Support Organization, 2022.
27.
KimESSharmaAMScissonsR, et al.Interpretation of peripheral arterial and venous Doppler waveforms: a consensus statement from the society for vascular medicine and society for vascular ultrasound. Vasc Med2020; 25: 484–506. DOI: 10.1177/1358863x20937665.
28.
LanCTsaiPRChenYS, et al.Prognostic factors for adult patients receiving extracorporeal membrane oxygenation as mechanical circulatory support--a 14 year experience at a medical center. Artif Organs2010; 34: E59–E64. DOI: 10.1111/j.1525-1594.2009.00909.x.
29.
HaleyMJFisherJCRuiz-ElizaldeAR, et al.Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child. J Pediatr Surg2009; 44: 437–440. DOI: 10.1016/j.jpedsurg.2008.09.010.
30.
WongJKMelvinALJoshiDJ, et al.Cannulation-related complications on veno-arterial extracorporeal membrane oxygenation: prevalence and effect on mortality. Artif Organs2017; 41: 827–834. DOI: 10.1111/aor.12880.
31.
TanakaDHiroseHCavarocchiN, et al.The impact of vascular complications on survival of patients on venoarterial extracorporeal membrane oxygenation. Ann Thorac Surg2016; 101: 1729–1734. DOI: 10.1016/j.athoracsur.2015.10.095.
32.
GanderJWFisherJCReichsteinAR, et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem. J Pediatr Surg2010; 45: 2136–2140. DOI: 10.1016/j.jpedsurg.2010.07.005.
33.
LorussoRWhitmanGMilojevicM, et al.2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg2021; 59: 12–53. DOI: 10.1093/ejcts/ezaa283.
34.
MarascoSFTutungiEVallanceSA, et al.A Phase 1 study of a novel bidirectional perfusion cannula in patients undergoing femoral cannulation for cardiac surgery. Innovations (Phila)2018; 13: 97–103. DOI: 10.1097/imi.0000000000000489.
35.
LiaoXChengZWangL, et al.Vascular complications of lower limb ischemia in patients with femoral venoarterial extracorporeal membrane oxygenation. Heart Surg Forum2020; 23: E305–e309. DOI: 10.1532/hsf.2969.
36.
YieKChonS-HDNaC-Y. Activated clotting time test alone is inadequate to optimize therapeutic heparin dosage adjustment during post-cardiopulmonary resuscitational extracorporeal membrane oxygenation (e-CPR). Perfusion2016; 31: 307–315. DOI: 10.1177/0267659115604710.
37.
BrunetJValetteXIvascauC, et al.Extracorporeal life support for refractory cardiac arrest or shock: a 10 year study. ASAIO J2015; 61: 676–681. DOI: 10.1097/MAT.0000000000000282.
38.
DaubinCLehouxPIvascauC, et al.Extracorporeal life support in severe drug intoxication: a retrospective cohort study of seventeen cases. Crit Care2009; 13: R138. DOI: 10.1186/cc8017.
39.
SonAYKhanhLNJoungHS, et al.Limb ischemia and bleeding in patients requiring venoarterial extracorporeal membrane oxygenation. J Vasc Surg2021; 73: 593–600. DOI: 10.1016/j.jvs.2020.05.071.
40.
SmithAHardisonDBridgesB, et al.Red blood cell transfusion volume and mortality among patients receiving extracorporeal membrane oxygenation. Perfusion2013; 28: 54–60. DOI: 10.1177/0267659112457969.
41.
BabarZUDSharmaASGanushchakYM, et al.An arterio-venous bridge for gradual weaning from adult veno-arterial extracorporeal life support. Perfusion2015; 30: 683–688. DOI: 10.1177/0267659115581197.
42.
StieglerHBrandlR. Importance of ultrasound for diagnosing periphereal arterial disease. Ultraschall Med2009; 30: 334–374. DOI: 10.1055/s-0028-1109452.
43.
KotvalPS. Doppler waveform parvus and tardus: a sign of proximal flow obstruction. J Ultrasound Med1989; 8: 435–440. DOI: 10.7863/jum.1989.8.8.435.
44.
GuptaPLyonsSHedgireS. Ultrasound imaging of the arterial system. Cardiovasc Diagn Ther2019; 9: S2–S13.
45.
SimonsJAgricolaSSmetsJ, et al.Duplex analysis of cannulated vessels in peripheral veno-arterial extracorporeal membrane oxygenation. Medicina (Kaunas)2022; 58: 671–705/29. DOI: 10.3390/medicina58050671.
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