Femoro-axillary versus femoro-femoral veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock: A monocentric retrospective study

Abstract

Rationale

For veno-arterial extracorporeal membrane oxygenation (ECMO), the femoral artery is the preferred cannulation site (femoro-femoral: Vf-Af). This results in retrograde aortic flow, which increases the left ventricular afterload and can lead to severe pulmonary edema and thrombosis of the cardiac chambers. Right axillary artery cannulation (femoral-axillary: Vf-Aa) provides partial anterograde aortic flow, which may prevent some complications. This study aimed to compare the 90-day mortality and complication rates between VF-AA and VF-AF.

Methods

Consecutive adult patients with cardiogenic shock who received peripheral VA-ECMO between 2013 and 2019 at our institution were retrospectively included. The exclusion criteria were refractory cardiac arrest, multiple VA-ECMO implantations due to vascular access changes, weaning failure, or ICU readmission. A statistical approach using inverse probability of treatment weighting was used to estimate the effect of the cannulation site on the outcomes. The primary endpoint was the 90-day mortality. The secondary endpoints were vascular access complications, stroke, and other complications related to retrograde blood flow. Outcomes were estimated using logistic regression analysis.

Results

VA-ECMO was performed on 534 patients. Patients with refractory cardiac arrest (n = 77 (14%)) and those supported by multiple VA-ECMO (n = 92, (17%)) were excluded. Out of the 333 patients studied (n = 209 Vf-Aa; n = 124 VF-AF), the main indications for VA-ECMO implantation were post-cardiotomy (33%, n = 109), dilated cardiomyopathy (20%, n = 66), post-cardiac transplantation (15%, n = 50), acute myocardial infarction (14%, n = 46) and other etiologies (18%, n = 62). The median SOFA score was 9 [7-11], and the crude 90-day mortality rate was 53% (n = 175). After IPTW, the 90-day mortality was similar in the Vf-Aa and VF-AF groups (54% vs 58%, IPTW-OR = 0.84 [0.54-1.29]). Axillary artery cannulation was associated with significantly fewer local infections (OR = 0.21, 95% CI:0.09-0.51), limb ischemia (OR = 0.37, 95% CI:0.17-0.84), bowel ischemia (OR = 0.16, 95% CI:0.05-0.51) and pulmonary edema (OR = 0.52, 95% CI:0.29-0.92) episodes, but with a higher rate of stroke (OR = 2.87, 95% CI:1.08-7.62) than femoral artery cannulation.

Conclusion

Compared to VF-AF, axillary cannulation was associated with similar 90-day mortality rates. The high rate of stroke associated with axillary artery cannulation requires further investigation.

Graphical Abstract

Keywords

cardiovascular surgery mechanical support propensity score 90-day mortality Vascular access extra corporeal membrane oxygenation

Get full access to this article

View all access options for this article.

References

Tonna

Boonstra

MacLaren

, et al. Extracorporeal life support organization registry international report 2022: 100,000 survivors. Am Soc Artif Intern Organs J 2024; 70(2): 131–143.

McDonagh

Metra

Adamo

, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2022; 24(1): 4–131.

Guglin

Zucker

Bazan

, et al. Venoarterial ECMO for adults: JACC scientific expert panel. J Am Coll Cardiol 2019; 73(6): 698–716.

Lorusso

Whitman

Milojevic

, et al. EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardio Thorac Surg. 2021;59(1):12–53.

Combes

Price

Slutsky

, et al. Temporary circulatory support for cardiogenic shock. Lancet 2020; 396(10245): 199–212.

Keller

. Management of peripheral venoarterial extracorporeal membrane oxygenation in cardiogenic shock. Crit Care Med 2019; 47(9): 1235–1242.

Vale

Papin

Kantor

. Flux rétrograde de la circulation extracorporelle avec oxygénateur à membrane. Conséquences, prévention et prise en charge. Sang Thromb Vaiss 2021; 33(4): 169–173.

Pisani

Braham

Brega

, et al. Right axillary artery cannulation for venoarterial extracorporeal membrane oxygenation: a retrospective single centre observational study. Eur J Cardio Thorac Surg 2021; 59(3): 601–609.

Andrei

Tran-Dinh

Provenchere

, et al. A quantified description of the interactions between the native cardiovascular system and femoro-femoral versus femoro-axillary extracorporeal life support using descending thoracic aorta velocity time integral. Artif Organs 2019; 43(7): 647–655.

10.

Schaefer

Distelmaier

Riebandt

, et al. Access site complications of postcardiotomy extracorporeal life support. J Thorac Cardiovasc Surg 2022; 164(5): 1546–1558.

11.

Buchtele

Staudinger

Schwameis

, et al. Feasibility and safety of watershed detection by contrast-enhanced ultrasound in patients receiving peripheral venoarterial extracorporeal membrane oxygenation: a prospective observational study. Crit Care 2020; 24(1): 126.

12.

Javidfar

Brodie

Costa

, et al. Subclavian artery cannulation for venoarterial extracorporeal membrane oxygenation. Am Soc Artif Intern Organs J 2012; 58(5): 494–498.

13.

Rali

Garry

Dieter

, et al. Extracorporeal life support for cardiogenic shock in adult congenital heart disease-an ELSO registry analysis. Am Soc Artif Intern Organs J 2023; 69(11): 984–992.

14.

Danial

Hajage

Nguyen

, et al. Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study. Intensive Care Med 2018; 44(12): 2153–2161.

15.

Azur

Stuart

Frangakis

, et al.

Multiple imputation by chained equations: what is it and how does it work?

Int J Methods Psychiatr Res 2011; 20(1): 40–49.

16.

White

Royston

Wood

. Multiple imputation using chained equations: issues and guidance for practice. Stat Med 2011; 30(4): 377–399.

17.

Lunceford

. Stratification and weighting via the propensity score in estimation of causal treatment effects: a comparative study. Stat Med 2017; 36(14): 2320.

18.

Rosenbaum

Rubin

. The central role of the propensity score in observational studies for causal effects. Biometrika 1983; 70(1): 41–55.

19.

Robins

Hernán

Brumback

. Marginal structural models and causal inference in epidemiology. Epidemiology 2000; 11(5): 550–560.

20.

Harder

Stuart

Anthony

. Propensity score techniques and the assessment of measured covariate balance to test causal associations in psychological research. Psychol Methods 2010; 15(3): 234–249.

21.

Austin

. The performance of different propensity-score methods for estimating differences in proportions (risk differences or absolute risk reductions) in observational studies. Stat Med 2010; 29(20): 2137–2148.

22.

Austin

. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharmaceut Stat 2011; 10(2): 150–161.

23.

Moussa

Rousse

Abou-Arab

, et al. Subclavian versus femoral arterial cannulations during extracorporeal membrane oxygenation: a propensity-matched comparison. J Heart Lung Transplant. 2022; 41(5). Available from: https://www.jhltonline.org/article/S1053-2498(22)00009-2/fulltext#

24.

Chamogeorgakis

Lima

Shafii

, et al. Outcomes of axillary artery side graft cannulation for extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2013; 145(4): 1088–1092.

25.

Wong

Melvin

Joshi

, et al. Cannulation-related complications on veno-arterial extracorporeal membrane oxygenation: prevalence and effect on mortality. Artif Organs 2017; 41(9): 827–834.

26.

Cevasco

Takayama

Ando

, et al. Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation. J Thorac Dis 2019; 11(4): 1676–1683.

27.

Numata

Itatani

Kanda

, et al. Blood flow analysis of the aortic arch using computational fluid dynamics. Eur J Cardio Thorac Surg 2016; 49(6): 1578–1585.

28.

Chhabra

Saini

Assistant

Dept. of Anatomy, Shri Bhausaheb Hire Govt. Medical College, Dhule, India . Morphometric study of arch of aorta and its branches. IJAR 2015; 3(2): 1079–1083.

29.

Tapia-Nañez

Landeros-Garcia

Sada-Treviño

, et al. Morphometry of the aortic arch and its branches. A computed tomography angiography-based study. Folia Morphol (Warsz) 2021; 80(3): 575–582.

30.

Pasrija

Bedeir

Jeudy

, et al. Harlequin syndrome during venoarterial extracorporeal membrane oxygenation. Radiology: Cardiothoracic Imaging 2019; 1(2): e190031.

31.

Wilson

Fisher

Caetano

, et al. Managing Harlequin Syndrome in VA-ECMO - do not forget the right ventricle. Perfusion 2022; 37(5): 526–529.

32.

Stevens

Callaghan

Forrest

, et al. Flow mixing during peripheral veno-arterial extra corporeal membrane oxygenation - a simulation study. J Biomech 2017; 55: 64–70.

33.

Honore

Barreto Gutierrez

Kugener

, et al.

Risk of harlequin syndrome during bi-femoral peripheral VA-ECMO: should we pay more attention to the watershed or try to change the venous cannulation site?

Crit Care 2020; 24(1): 450.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.59 MB