Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an increasingly adopted life-saving mechanical circulatory support for a number of potentially reversible or treatable cardiac diseases. It is also started as a bridge-to-transplantation/ventricular assist device in the case of unrecoverable cardiac or cardio-respiratory illness. In recent years, principally for non-post-cardiotomy shock, peripheral cannulation using the femoral vessels has been the approach of choice because it does not need the chest opening, can be quickly established, can be applied percutaneously, and is less likely to cause bleeding and infections than central cannulation. Peripheral ECMO, however, is characterized by a higher rate of vascular complications. The mechanisms of such adverse events are often multifactorial, including suboptimal arterial perfusion and hemodynamic instability due to the underlying disease, peripheral vascular disease, and placement of cannulas that nearly occlude the vessel. The effect of femoral artery damage and/or significant reduced limb perfusion can be devastating because limb ischemia can lead to compartment syndrome, requiring fasciotomy and, occasionally, even limb amputation, thereby negatively impacting hospital stay, long-term functional outcomes, and survival. Data on this topic are highly fragmentary, and there are no clear-cut recommendations. Accordingly, the strategies adopted to cope with this complication vary a great deal, ranging from preventive placement of antegrade distal perfusion cannulas to rescue interventions and vascular surgery after the complication has manifested. This review aims to provide a comprehensive overview of limb ischemia during femoral cannulation for VA-ECMO in adults, focusing on incidence, tools for early diagnosis, risk factors, and preventive and treating strategies.

/pdf/limb-ischemia-in-peripheral-veno-arterial-extracorporeal-1w987b0buj.pdf

Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment

Femoral artery surgical cannulation is the reference for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults. However, the less invasive percutaneous approach has been associated with lower rates of complications. This retrospective study compared complication rates and overall survival in a large series of patients who received surgical or percutaneous peripheral VA-ECMO. All consecutive patients implanted with VA-ECMO between January 2015 and December 2017 in a high ECMO-volume university hospital were included. Surgical cannulation was the only approach until late 2016 after which the percutaneous approach became the first line strategy. Propensity score framework analyzes were used to compare outcomes of percutaneous and surgical groups while controlling for confounders. Among the 814 patients who received VA-ECMO (485 surgical and 329 percutaneous), propensity-score matching selected 266 unique pairs of patients with similar characteristics. Percutaneous cannulation was associated with fewer local infections (16.5% versus 27.8%, p = 0.001), similar rates of limb ischemia (8.6% versus 12.4%, p = 0.347) and sensory-motor complications (2.6% versus 2.3%, p = 0.779) and improved 30-day survival (63.8% versus 56.3%, p = 0.034). However, more vascular complications following decannulation (14.7% versus 3.4%, p < 0.001), mainly persistent bleeding requiring surgical revision (9.4% vs. 1.5%, p < 0.001), occurred after percutaneous cannulation. Compared to the surgical approach, percutaneous cannulation for peripheral VA-ECMO was associated with fewer local infections, similar rates of ischemia and sensory-motor complications and improved 30-day survival. The higher rate of vascular complications following decannulation suggests that improvements in cannula removal techniques are needed to further improve patients’ outcomes after percutaneous cannulation.

Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study

Background: The incidence of coronary artery disease (CAD) among patients with refractory out-of-hospital (OOH) ventricular fibrillation/ventricular tachycardia (VF/VT) cardiac arrest is unknown. O...

Abstract 19432: Burden of Coronary Artery Disease in Patients With Out-of-Hospital Refractory Ventricular Fibrillation Cardiac Arrest

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible aetiology. Currently, there are no randomised, controlled studies on eCPR. Thus, prospective validated predictors of benefit and outcome are lacking. Currently, selection criteria and procedure techniques differ across hospitals and standardised algorithms are lacking. Based on expert opinion, the present consensus statement provides a first standardised treatment algorithm for eCPR.

Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR): consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC.

Background Few patients survive after out‐of‐hospital cardiac arrest and any measure that improve circulation during cardiopulmonary resuscitation is beneficial. Animal studies support that resusci...

Feasibility of Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta in Non-Traumatic Out-of-Hospital Cardiac Arrest.

Improving cannulation time for extracorporeal life support in refractory cardiac arrest of presumed cardiac cause - Comparison of two percutaneous cannulation techniques in the catheterization laboratory in a center without on-site cardiovascular surgery.

Out-of-hospital cardiac arrest (OHCA) is a major public health issue worldwide, with a current increasing incidence of initial non-shockable rhythms that are associated with worse neurological and global outcome as compared with shockable rhythms (1,2). However, last available registries reported improvements in related short and long term survival rates in non-shockable cardiac arrest (CA) patients (3). The benefit of targeted temperature management (TTM) between 32 and 36 ℃ for at least 24 hours on neurological recovery and survival is established in OHCA from initial shockable rhythms (4,5). Based on this available evidence and consensus of expert opinions, international guidelines suggest the use of TTM in post-CA care for comatose CA patients after initial non-shockable rhythm.

Targeted temperature management for non-shockable cardiac arrests: the debate must go on

Anti-parietal cell autoimmunity is associated with an accelerated decline of lung function in IPF patients

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Improving cannulation time for extracorporeal life support in refractory cardiac arrest of presumed cardiac cause - Comparison of two percutaneous cannulation techniques in the catheterization laboratory in a center without on-site cardiovascular surgery.

Targeted temperature management for non-shockable cardiac arrests: the debate must go on

Anti-parietal cell autoimmunity is associated with an accelerated decline of lung function in IPF patients