Arterial chimney graft cannulation for interventional lung assist

Meta-Analysis of the Effect of Vascular Complications on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has become an accepted treatment modality in the management of select patients with cardiopulmonary failure. As a result, its use has increased significantly over the past decade. However, the effect of complications on mortality is not clearly established. We performed a comprehensive, up-to-date meta-analysis of peer-reviewed literature focusing on the effect of vascular complications (VCs) on the survival of patients receiving venoarterial ECMO (VA-ECMO) with femoral cannulation.

METHODS

A systematic search of 4 different databases (PubMed, Embase, Scopus, and Web of Science) was conducted from their inception to mid-September of 2019. To keep the pooled analysis current, only studies published within the past 5 years were included. Mortality was analyzed based on presence or absence of VCs. Studies with less then 10 patients, with incomplete mortality data, and not accessible in the English language were excluded.

RESULTS

Ten studies were included in the analysis encompassing 1,643 patients over a 5-year period. There were 369 patients with a cumulative VC rate of 22.5% (range 9.4 to 43.9%). The pooled mortality rate for patients with and without VCs was 69.6% and 56.8%, respectively. Meta-analysis demonstrated a significant correlation between VCs and mortality with a relative risk (RR) of 1.36 (95% confidence interval (CI), 1.15-1.60; P = 0.0004). Covariate-adjusted meta-regression analysis revealed an inverse relationship between age and mortality for VCs, with an RR of 1.33 (95% CI, 1.15-1.54; P = 0.0184), and direct relationship between female gender and mortality from VCs, RR 1.39 (95% CI, 1.21-1.59; P = 0.0165).

CONCLUSIONS

The most recently available data published in the literature demonstrate a significant correlation of VCs with mortality. Therefore, aggressive attempts should be made to minimize VCs in patients with femoral VA-ECMO cannulation.

Extracorporeal Support for Chronic Obstructive Pulmonary Disease: A Bright Future

In the past the only option for the treatment of respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease (aeCOPD) was invasive mechanical ventilation. In recent decades, the potential for extracorporeal carbon dioxide (CO₂) removal has been realized. We review the various types of extracorporeal CO₂ removal, outline the optimal use of these therapies for aeCOPD, and make suggestions for future controlled trials. We also describe the advantages and requirements for an ideal long-term ambulatory CO₂ removal system for palliation of COPD.

Modified T-Graft for Extracorporeal Membrane Oxygenation in a Patient with Small-Caliber Femoral Arteries

Extracorporeal membrane oxygenation (ECMO) is generally used as a last resort to provide cardiopulmonary support in patients whose advanced cardiac or respiratory failure does not respond to less invasive treatments. Lower-limb ischemia secondary to the large diameter of the arterial cannula is one of ECMO's major limitations: in patients who have small-caliber arteries, the cannulas can reduce native blood flow. The creation of a T-graft-a well-described technique to avoid limb ischemia-enables flow into the ECMO cannula without jeopardizing blood flow to the limb. However, leaving the graft exposed through an open groin wound can result in dislodgment, and it increases the risk of infection. We describe our modification of a conventional T-graft in an 18-year-old woman who had systolic heart failure, acute respiratory distress syndrome, and small-caliber femoral vessels. We tunneled a polytetrafluoroethylene graft inside a Dacron graft, then ran the combined graft through a subcutaneous tunnel similar to that created for a peripheral bypass. Thus, the graft was protected from environmental exposure and the risk of infection. Our technique seems safer and more secure than the original T-graft technique, and we recommend its consideration during ECMO cannulation.

Arterial vascular complications in peripheral extracorporeal membrane oxygenation support: a review of techniques and outcomes

Peripheral venoarterial extracorporeal membrane oxygenation support provides prolonged support in the event of acute or acute-on-chronic cardiac and/or respiratory failure. This support serves as a bridge to recovery, decision-making, heart transplantation or ventricular-assist device implantation. It can be implanted either through a percutaneous approach using Seldinger's technique or via an open approach via the common femoral artery or the axillary artery. Early and late arterial vascular complications remain an important issue, with rates of up to 28% with femoral and axillary cannulation sites. Among them, limb ischemia requires prompt diagnosis and management to avoid limb amputation. In the case of peripheral artery cannulation, ipsilateral distal limb perfusion to prevent acute limb ischemia can be performed via a single lumen catheter through the artery or via the 'chimney graft' technique during extracorporeal membrane oxygenation implantation.