Eastern Cardiothoracic Surgical Society

Lower Extremity Complications in Patients Undergoing Peripheral Arteriovenous Extracorporeal Membrane Oxygenator Support
Matthew J. Kramer, Sofiane Lasar, Michael Acker, Nimesh Desai, Joseph Bavaria, Prashanth Vallabhajosyula, University of Pennsylvania, Philadelphia, PA

OBJECTIVE: Patients undergoing emergent peripheral arteriovenous (AV ECMO) via femoral cannulation were evaluated for lower extremity complications based on type of ipsilateral limb perfusion strategy.

METHODS: In retrospective review (2008 to 2013), 105 out of 250 patients met criteria. For limb perfusion, patients underwent no superficial femoral artery (SFA) cannulation (NoSFA group, n=35), or percutaneous SFA cannulation via ultrasound guidance (PSFA group, n=23), or open cut-down SFA cannulation (OpenSFA group, n=47).

RESULTS: In the entire cohort, mean age was 50 + 16 years, 63% (n=67) were male, 30-day/ in-hospital mortality was 65% (n=68), with lower extremity complication rate of 13% (n=14). Lower extremity complication rate was significantly lower in the OpenSFA group (n=1, 2%) compared to NoSFA (n=7 (20%), p=0.02), and PSFA (n=6 (26%), p=0.004) groups. Peripheral complication rate was similar between the NoSFA and PSFA groups (p=0.75). These complications required thromboembolectomy (n=2), fasciotomy (n=3), and emergent SFA cannula placement (n=2) in OpenSFA group. In the PSFA group, thromboembolectomy (n=2), fasciotomy (n=1), amputation (n=1), SFA cannula revision (n=1) were required. In the OpenSFA group, one patient had loss of distal signals from multiorgan failure, without technical complications.

CONCLUSIONS: Lack of ipsilateral limb perfusion in peripheral ECMO is associated with a high lower extremity complication rate. Percutaneous SFA cannulation performed via ultrasound guidance is associated with high limb ischemia complications. Percutaneous SFA cannulation should most likely be performed under fluoroscopic guidance, with angiographic confirmation. Open SFA approach remains a safe alternative to the other strategies.