Vascular Complications of Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Regression Analysis

Occurrence, predictors, and management of late vascular complications following extracorporeal membrane oxygenation

OBJECTIVE

Vascular complications (VCs) associated with extracorporeal membrane oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VCs following ECMO; this study aims to assess occurrence and management practices of late VCs following discharge.

METHODS

A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1, 2019, and December 31, 2020. Primary outcomes were to categorize and determine the rate of late VCs. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations.

RESULTS

A total of 229 patients were identified, of which 50.6% (n = 116) survived until discharge. Late VCs occurred in 7.8% of the surviving cohort (n = 9/116); with a median time until presentation of 150 days (interquartile range, 83-251 days). The most common late VC was infection (n = 5; 55.6%) followed by progression to limb-threatening ischemia (n = 4; 44.4%). Urgent procedures were required in 55.6% of patients (n = 5), whereas 44.4% (n = 4) were elective interventions. Interventions performed for management of late VCs included lower extremity arterial revascularization (n = 6; 66.7%), major (n = 1; 11.1%) or minor amputation (n = 1; 11.1%), and wound debridement (n = 1; 11.1%). The majority of patients presenting with late VCs had initially been cannulated for peripheral VA ECMO (n = 8; 88.9%), and one patient (11.1%) was cannulated for peripheral VV ECMO. VCs during index hospitalization were seen in 77.8% of patients (n = 7) returning with late VCs. Odds for late VCs were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal cardiopulmonary resuscitation (odds ratio, 8.4; P = .016) and in cases where patients had experienced an index VC during index hospitalization (odds ratio, 19.3; P = .001).

CONCLUSIONS

Late vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb.

Vascular Complications in Extracorporeal Membrane Oxygenation-A Narrative Review

The establishment of a peripheral ECMO circuit can lead to significant arterial and venous complications in 10-30% of patients. Vascular complications, particularly acute limb ischemia, are associated with worsening overall outcomes. Limb ischemia occurs significantly more frequently in the early stages of VA ECMO than in VV ECMO. Mechanisms of limb ischemia include arterial obstruction, cannulation injury, loss of pulsatile flow, thromboembolism, venous stasis from compressive obstruction with large venous cannulas, and systemic vasoconstriction due to shock and pharmacologic vasoconstriction. The care team may use several mitigation strategies to prevent limb ischemia. Arterial and venous complications can be mitigated by careful access site selection, minimizing cannula size, placement of distal perfusion and/or outflow catheter(s), and continuous NIRS monitoring. Rapid intervention, when ischemia or compartment syndrome occurs, can reduce limb loss but may not affect the mortality and morbidity of the ECMO patient in the long term due to their underlying conditions and the etiology of the ECMO need.

Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism

BACKGROUND

Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE.

METHODS

A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE.

RESULTS

In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes.

CONCLUSIONS

The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.

Echocardiographic and Point-of-Care Ultrasonography (POCUS) Guidance in the Management of the ECMO Patient

Veno-arterial (V-A) and Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) support is increasingly utilized for acute cardiogenic shock and/or respiratory failure. Echocardiography and point-of-care ultrasonography (POCUS) play a critical role in the selection and management of these critically ill patients, however, there are limited guidelines regarding their application. This comprehensive review describes current and potential application of echocardiography and POCUS for pre-ECMO assessment and patient selection, cannulation guidance with emphasis on dual-lumen configurations, diagnosis of ECMO complications and trouble-shooting of cannula malposition, diagnosis of common cardiac or pulmonary pathologies, and assessment of ECMO weaning appropriateness including identification of the aortic mixing point in V-A ECMO.

Evolution of distal limb perfusion management in adult peripheral venoarterial extracorporeal membrane oxygenation with femoral artery cannulation

Limb ischaemia is a clinically relevant complication of venoarterial extracorporeal membrane oxygenation (VA ECMO) with femoral artery cannulation. No selective distal perfusion or other advanced techniques were used in the past to maintain adequate distal limb perfusion. A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.

Analysis of adverse events related to extracorporeal membrane oxygenation from a nationwide database of patient-safety accidents in Japan

Although adverse events related to extracorporeal membrane oxygenation have been reported, epidemiological data on life-threatening events are insufficient to study the causes of such adverse events. Data from the Japan Council for Quality Health Care database were retrospectively analyzed. The adverse events extracted from this national database included events associated with extracorporeal membrane oxygenation reported between January 2010 and December 2021. We identified 178 adverse events related to extracorporeal membrane oxygenation. At least 41 (23%) and 47 (26%) accidents resulted in death and residual disability, respectively. The most common adverse events were cannula malposition (28%), decannulation (19%), and bleeding (15%). Among patients with cannula malposition, 38% did not undergo fluoroscopy-guided or ultrasound-guided cannulation, 54% required surgical treatment, and 18% required trans-arterial embolization. In this epidemiological study in Japan, 23% of the adverse events related to extracorporeal membrane oxygenation had fatal outcomes. Our findings suggest that a training system for cannulation techniques may be needed, and hospitals offering extracorporeal membrane oxygenation should perform emergency surgeries.

Arterio-venous fistula causing acute right heart failure: A rare complication of veno-arterial extracorporeal membrane oxygenation

Introduction: Vascular complications are a major issue in V-A ECMO and can affect long term outcome. Among these, Artero-Venous (AV) fistulas may lead to right heart failure.Case History: A 73-years patient supported with V-A ECMO for post-cardiotomy biventricular failure developed right heart failure after V-A ECMO decannulation, requiring V-A ECMO recannulation. The presence of an AV femoral fistula was incidentally revealed during femoral vein cannulation, from which oxygenated blood was unexpectedly drawn. The angiographic assessment confirmed the presence of a fistula between superficial femoral artery and vein, at the site of the first venous ECMO cannulation. This was caused by the venous cannula that inadvertently passed across the artery and created an AV fistula that was opened by the venous cannula removal. The exclusion of the endovascular fistula allowed the right heart failure resolution.Conclusions: In the presence of right heart failure after recent vascular manipulation, AV fistula should be ruled out.

Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies

PURPOSE

Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit.

METHODS

We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model.

RESULTS

We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66).

CONCLUSION

In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with other curative therapies. We aimed to characterise the mortality of adults with HRPE treated with ECMO, identify factors associated with mortality, and compare different adjunct curative therapies.

METHODS

We conducted a systematic review and meta-analysis, searching four international databases from their inception until 25 June 2023 for studies reporting on more than five patients receiving ECMO for HRPE. Random-effects meta-analyses were conducted. The primary outcome was in-hospital mortality. A subgroup analysis investigating the outcomes with curative treatment for HRPE was also performed. The intra-study risk of bias and the certainty of evidence were also assessed. This study was registered with PROSPERO (CRD42022297518).

RESULTS

A total of 39 observational studies involving 6409 patients receiving ECMO for HRPE were included in the meta-analysis. The pooled mortality was 42.8% (95% confidence interval [CI]: 37.2% to 48.7%, moderate certainty). Patients treated with ECMO and catheter-directed therapy (28.6%) had significantly lower mortality (p < 0.0001) compared to those treated with ECMO and systemic thrombolysis (57.0%). Cardiac arrest prior to ECMO initiation (regression coefficient [B]: 1.77, 95%-CI: 0.29 to 3.25, p = 0.018) and pre-ECMO heart rate (B: -0.076, 95%-CI: -0.12 to 0.035, p = 0.0003) were significantly associated with mortality. The pooled risk ratio when comparing mortality between patients on ECMO and those not on ECMO was 1.51 (95%-CI: 1.07 to 2.14, p < 0.01) in favour of ECMO. The pooled mortality was 55.2% (95%-CI: 47.7% to 62.6%), using trim-and-fill analysis to account for the significant publication bias.

CONCLUSIONS

More than 50% of patients receiving ECMO for HRPE survive. While outcomes may vary based on the curative therapy used, early ECMO should be considered as a stabilising measure when treating patients with HRPE. Patients treated concurrently with systemic thrombolysis have higher mortality than those receiving ECMO alone or with other curative therapies, particularly catheter-directed therapies. Further studies are required to explore ECMO vs. non-ECMO therapies in view of currently heterogenous datasets.

Current status of ECMO for massive pulmonary embolism

Massive pulmonary embolism (MPE) carries significant 30-day mortality and is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Given the continued high mortality associated with MPE, there has been ongoing interest in utilizing extracorporeal membrane oxygenation (ECMO) to provide oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and RV pressure will improve outcomes. Two modalities can be employed: Veno-arterial-ECMO is a reliable process to decrease RV overload and improve RV function, thus allowing for hemodynamic stability and restoration of tissue oxygenation. Veno-venous ECMO can support oxygenation but is not designed to help circulation. Several societal guidelines now suggest using ECMO in MPE with interventional therapy. There are three strategies for ECMO utilization in MPE: bridge to definitive interventional therapy, sole therapy, and recovery after interventional treatment. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Considerable heterogeneity in studies is a significant weakness of the available literature. Applying ECMO is also associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, which must be factored into the outcomes. The application of ECMO in MPE should be combined with an aggressive pulmonary interventional program and should strictly adhere to the current selection criteria.

Short-Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation serves as a crucial mechanical circulatory support for pediatric patients with severe heart diseases, but the mortality rate remains high. The objective of this study was to assess the short-term mortality in these patients.

METHODS AND RESULTS

We systematically searched PubMed, Embase, and Cochrane Library for observational studies that evaluated the short-term mortality of pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation. To estimate short-term mortality, we used random-effects meta-analysis. Furthermore, we conducted meta-regression and binomial regression analyses to investigate the risk factors associated with the outcome of interest. We systematically reviewed 28 eligible references encompassing a total of 1736 patients. The pooled analysis demonstrated a short-term mortality (defined as in-hospital or 30-day mortality) of 45.6% (95% CI, 38.7%-52.4%). We found a significant difference (P<0.001) in mortality rates between acute fulminant myocarditis and congenital heart disease, with acute fulminant myocarditis exhibiting a lower mortality rate. Our findings revealed a negative correlation between older age and weight and short-term mortality in patients undergoing veno-arterial extracorporeal membrane oxygenation. Male sex, bleeding, renal damage, and central cannulation were associated with an increased risk of short-term mortality.

CONCLUSIONS

The short-term mortality among pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation for severe heart diseases was 45.6%. Patients with acute fulminant myocarditis exhibited more favorable survival rates compared with those with congenital heart disease. Several risk factors, including male sex, bleeding, renal damage, and central cannulation contributed to an increased risk of short-term mortality. Conversely, older age and greater weight appeared to be protective factors.

Association of Prophylactic Distal Perfusion Cannulation With Mortality in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation

Prophylactic distal perfusion cannulation (PDPC) is protectively associated with limb ischemia in patients with cardiogenic shock (CS) receiving femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, evidence supporting its benefits beyond limb ischemia reduction is scarce. We aimed to investigate whether PDPC, compared with no-PDPC, is associated with a lower risk of mortality in patients receiving VA-ECMO. From a multicenter registry, we identified 479 patients who underwent VA-ECMO support for refractory CS. The association of PDPC with 30-day mortality was assessed using multiple methods, including instrumental variable analysis, overlap weighting, and propensity score matching. Of the 479 patients, 154 (32.2%) received PDPC. The 30-day mortality rate was 33.1% in the PDPC group and 53.2% in the no-PDPC group. The instrumental variable analysis showed a protective association of PDPC with 30-day mortality (absolute risk difference -16.7%, 95% confidence interval -31.3% to -2.1%; relative risk 0.68, 95% confidence interval 0.40 to 0.96). The findings were consistent in the overlap-weighted analysis (hazard ratio 0.68, 95% confidence interval 0.48 to 0.98) and in the propensity score-matched analysis (hazard ratio 0.67, 95% confidence interval 0.45 to 1.00). There were no significant differences in safety outcomes, including stroke, ECMO site bleeding, gastrointestinal bleeding, and sepsis, between PDPC and no-PDPC. In conclusion, PDPC was associated with a lower risk of mortality at 30 days in patients with CS receiving VA-ECMO. The efficacy and safety of PDPC merit evaluation in future randomized studies. Clinical trial registration: ClinicalTrials.gov; NCT02985008.

Perspectives and Considerations of IABP in the Era of ECMO for Cardiogenic Shock

The development of mechanical circulatory support (MCS) has been rapid, and its use worldwide in patients with cardiogenic shock is increasingly widespread. However, current statistical data and clinical research do not demonstrate its significant improvement in the patient prognosis. This review focuses on the widely used intra-aortic balloon pumps (IABP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO), analyzing and comparing their characteristics, efficacy, risk of complications, and the current exploration status of left ventricular mechanical unloading. Subsequently, we propose a rational approach to viewing the negative outcomes of current MCS, and look ahead to the future development trends of IABP.

Feasibility of HEMS performed prehospital extracorporeal-cardiopulmonary resuscitation in paediatric cardiac arrests; two case reports

INTRODUCTION

A broad range of pathophysiologic conditions can lead to cardiopulmonary arrest in children. Some of these children suffer from refractory cardiac arrest, not responding to basic and advanced life support. Extracorporeal-Cardiopulmonary Resuscitation (E-CPR) might be a life-saving option for this group. Currently this therapy is only performed in-hospital, often necessitating long transport times, thereby negatively impacting eligibility and chances of survival. We present the first two cases of prehospital E-CPR in children performed by regular Helicopter Emergency Medical Services (HEMS).

CASE PRESENTATIONS

The first patient was a previously healthy 7 year old boy who was feeling unwell for a couple of days due to influenza. His course deteriorated into a witnessed collapse. Direct bystander CPR and subsequent ambulance advanced life support was unsuccessful in establishing a perfusing rhythm. While doing chest compressions, the patient was seen moving both his arms and making spontaneous breathing efforts. Echocardiography however revealed a severe left ventricular impairment (near standstill). The second patient was a 15 year old girl, known with bronchial asthma and poor medication compliance. She suffered yet another asthmatic attack, so severe that she progressed into cardiac arrest in front of the attending ambulance and HEMS crews. Despite maximum bronchodilator therapy, intubation and the exclusion of tension pneumothoraxes and dynamic hyperinflation, no cardiac output was achieved.

INTERVENTION

After consultation with the nearest paediatric E-CPR facilities, both patients were on-scene cannulated by regular HEMS. The femoral artery and vein were cannulated (15-17Fr and 21Fr respectively) under direct ultrasound guidance using an out-of-plane Seldinger approach. Extracorporeal Life Support flow of 2.1 and 3.8 l/min was established in 20 and 16 min respectively (including preparation and cannulation). Both patients were transported uneventfully to the nearest paediatric intensive care with spontaneous breathing efforts and reactive pupils during transport.

CONCLUSION

This case-series shows that a properly trained regular HEMS crew of only two health care professionals (doctor and flight nurse) can establish E-CPR on-scene in (older) children. Ambulance transport with ongoing CPR is challenging, even more so in children since transportation times tend to be longer compared to adults and automatic chest compression devices are often unsuitable and/or unapproved for children. Prehospital cannulation of susceptible E-CPR candidates has the potential to reduce low-flow time and offer E-CPR therapy to a wider group of children suffering refractory cardiac arrest.

Percutaneous cannulation is associated with lower rate of severe neurological complication in femoro-femoral ECPR: results from the Extracorporeal Life Support Organization Registry

BACKGROUND

Percutaneous cannulation is now accepted as the first-line strategy for extracorporeal cardiopulmonary resuscitation (ECPR) in adults. However, previous studies comparing percutaneous cannulation to surgical cannulation have been limited by small sample size and single-center settings. This study aimed to compare in-hospital outcomes in cardiac arrest (CA) patients who received femoro-femoral ECPR with percutaneous vs surgical cannulation.

METHODS

Adults with refractory CA treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral ECPR between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was severe neurological complication. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes.

RESULTS

Among 3575 patients meeting study inclusion, 2749 (77%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 18% to 89% over the study period (p < 0.001 for trend). Severe neurological complication (13% vs 19%; p < 0.001) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rate of severe neurological complication (odds ratio [OR] 0.62; 95% CI 0.46-0.83; p = 0.002), similar rates of in-hospital mortality (OR 0.93; 95% CI 0.73-1.17; p = 0.522), limb ischemia (OR 0.84; 95% CI 0.58-1.20; p = 0.341) and cannulation site bleeding (OR 0.90; 95% CI 0.66-1.22; p = 0.471). The comparison of outcomes provided similar results across different levels of center percutaneous experience or center ECPR volume.

CONCLUSIONS

Among adults receiving ECPR, percutaneous cannulation was associated with probable lower rate of severe neurological complication, and similar rates of in-hospital mortality, limb ischemia and cannulation site bleeding.

Acute Limb Ischaemia during ECMO Support: A 6-Year Experience

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock is rising. Acute limb ischaemia remains one of the main complications after ECMO initiation. We analysed 104 patients from our databank from January 2015 to December 2021 who were supported with mobile ECMO therapy. We aimed to identify the impact of acute limb ischaemia on short-term outcomes in patients placed on ECMO in our institution. The main indication for ECMO therapy was left ventricular (LV) failure with cardiogenic shock (57.7%). Diameters of arterial cannulas (p = 0.365) showed no significant differences between both groups. Furthermore, concomitant intra-aortic balloon pump (IABP, p = 0.589) and Impella (p = 0.385) implantation did not differ significantly between both groups. Distal leg perfusion was established in approximately 70% of patients in two groups with no statistically significant difference (p = 0.960). Acute limb ischaemia occurred in 18.3% of cases (n = 19). In-hospital mortality was not significantly different (p = 0.799) in both groups. However, the bleeding rate was significantly higher (p = 0.005) in the limb ischaemia group compared to the no-limb ischaemia group. Therefore, early diagnosis and prevention of acute limb ischaemia might decrease haemorrhage complications in patients during ECMO therapy.

Levosimendan in patients undergoing extracorporeal membrane oxygenation after cardiac surgery: an emulated target trial using observational data

BACKGROUND

Retrospective cohorts have suggested that levosimendan may facilitate the weaning of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We therefore studied this clinical question by emulating a randomized trial with observational data.

METHODS

All patients with refractory postcardiotomy cardiogenic shock and assisted with VA-ECMO, admitted to a surgical intensive care unit at La Pitié-Salpêtrière Hospital between 2016 and 2019, were eligible. To avoid immortal-time bias, we emulated a target trial sequentially comparing levosimendan administration versus no levosimendan administration in patients treated with VA-ECMO. The primary outcome was time to successful ECMO weaning. The secondary outcomes were 30-day and 1-year mortality. We performed a multivariable analysis to adjust for confounding at baseline.

RESULTS

Two hundred and thirty-nine patients were included in the study allowing building a nested trials cohort of 1434 copies of patients. No association of levosimendan treatment and VA-ECMO weaning was found (HR = 0.91, [0.57; 1.45], p = 0.659 in multivariable analysis), or 30-day mortality (OR = 1.03, [0.52; 2.03], p = 0.940) and 1-year mortality (OR = 1.00, [0.53; 1.89], p = 0.999).

CONCLUSIONS

Using the emulated target trial framework, this study did not find any association of levosimendan treatment and ECMO weaning success after postcardiotomy cardiogenic shock. However, the population of interest remains heterogeneous and subgroups might benefit from levosimendan.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Meta-analysis of extracorporeal membrane oxygenation in combination with intra-aortic balloon pump vs. extracorporeal membrane oxygenation only in patients with cardiogenic shock due to acute myocardial infarction

Background

Incidence and mortality of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) remain high despite substantial therapy improvements in acute percutaneous coronary intervention over the last decades. Unloading the left ventricle in patients with Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be performed by using an intra-aortic balloon pumps' (IABP) afterload reduction, which might be especially beneficial in AMI patients with CS.

Objective

The objective of this meta-analysis was to assess the effect of VA-ECMO + IABP vs. VA-ECMO treatment on the mortality of patients with CS due to AMI.

Methods

A systematic literature search was performed using EMBASE, COCHRANE, and MEDLINE databases. Studies comparing the effect of VA-ECMO + IABP vs. VA-ECMO on mortality of patients with AMI were included. Meta-analyses were performed to analyze the effect of the chosen treatment on 30-day/in-hospital mortality.

Results

Twelve studies were identified by the literature search, including a total of 5,063 patients, 81.5% were male and the mean age was 65.9 years. One thousand one hundred and thirty-six patients received treatment with VA-ECMO in combination with IABP and 2,964 patients received VA-ECMO treatment only. The performed meta-analysis showed decreased mortality at 30-days/in-hospital after VA-ECMO + IABP compared to VA-ECMO only for patients with cardiogenic shock after AMI (OR 0.36, 95% CI 0.30-0.44, P≤0.001). Combination of VA-ECMO + IABP was associated with higher rates of weaning success (OR 0.29, 95% CI 0.16-0.53, P < 0.001) without an increase of vascular access complications (OR 0.85, 95% CI 0.35-2.08, P = 0.72).

Conclusion

In this meta-analysis, combination therapy of VA-ECMO + IABP was superior to VA-ECMO only therapy in patients with CS due to AMI. In the absence of randomized data, these results are hypothesis generating only.

How to Do It: A Safe Bedside Protocol for Dual-Lumen Right Internal Jugular Cannulation for Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients With Severe Acute Respiratory Distress Syndrome

In appropriately selected patients with COVID-19 acute respiratory distress syndrome, venovenous extracorporeal membrane oxygenation (VV ECMO) may offer a promising bridge to lung recovery or lung transplantation if lung recovery fails. Although the cannulation technique for VV ECMO via a right internal jugular (RIJ) dual-lumen catheter (DLC) requires expertise and guidance by either fluoroscopy or transesophageal echocardiography (TEE), it offers theoretical circulatory support advantages by using bicaval venous drainage to deliver oxygenated blood systemically with minimal recirculation as compared with the femoral vein and RIJ dual-site cannula configuration. In addition, patients are often too unstable to transport safely to an operating room or catheterization laboratory, and fluoroscopy is not always readily available to guide RIJ DLC placement. Here, we provide a comprehensive description of a safe, bedside protocol for VV ECMO cannulation via a RIJ DLC under TEE guidance. We will report our center's experience (March 30, 2020 to November 21, 2021) and discuss important hemodynamic, safety, and infection control considerations.

The Preventive Effect of Distal Perfusion Catheters on Vascular Complications in Patients Undergoing Venous Artery Extracorporeal Membrane Oxygenation

Objective

To investigate the preventive effect of distal perfusion catheters (DPCs) on vascular complications in patients undergoing venous artery extracorporeal membrane oxygenation (VA-ECMO).

Methods

Patients who underwent VA-ECMO through a femoral approach in our hospital were included in this study, and they were divided into two groups according to their use of DPC. Clinical indicators were compared between the two groups, including the ECMO running time, intensive care unit (ICU) time, length of hospital stay, ECMO auxiliary results, the incidence of limb ischemia and vascular complications.

Results

In total, 250 patients were included in this study, including the DPC group (age: 48 [32-62] years old, 58.4% male, n = 125) and the non-DPC group (age: 51 [36-63] years old, 65.6% male, n = 125). The DPC group was less likely to have limb complications than the non-DPC group (6.4% vs 17.6%, P = 0.006), mainly resulting from distal ischemia (4.0% vs 15.2%, P = 0.003) and necrosis (1.6% vs 9.6%, P = 0.006). The ECMO duration had a median of 92.3 (75.7-109) h in the DPC group and 71.2 (59.4-82.8) h in the DPC group, with a difference close to the statistical threshold (P = 0.054). There was no significant difference in ICU time or length of hospital stay between the two groups. The multivariate analysis showed that the DPC implantation was negatively associated with limb complications (odds ratio: 0.265, 95% confidence interval: 0.107-0.657, P = 0.004) after adjustment for confounding factors.

Conclusion

Distal perfusion catheter placement might be associated with a decreased risk of vascular complications and limb ischemia in patients undergoing femoral VA-ECMO cannulation. Further randomised studies are still needed to verify its benefit on clinical outcomes.

Routine whole-body CT identifies clinically significant findings in patients supported with veno-venous extracorporeal membrane oxygenation

AIM

To determine the yield of routine whole-body computed tomography (CT) following extracorporeal membrane oxygenation (ECMO) initiation and to assess the association of these findings with prognosis.

MATERIALS AND METHODS

One hundred and ninety-eight consecutive patients with acute respiratory failure admitted for ECMO support between January 2015 and December 2019 who underwent whole-body CT performed within 48 h of ECMO initiation were examined in this single-institution retrospective study. CT findings were divided into three categories: clinically significant findings that may affect immediate management strategy or short-term outcomes; findings not related to hospital stay or outcome but require further workup; and benign findings that do not require further investigation. Logistic regression analysis was used to assess the association of CT findings with 7- and 30-day survival.

RESULTS

Clinically significant findings were present in 147 (74%) patients, findings requiring further workup were found in 82 (41%) patients, and benign findings were identified in 180 (90%) of the patients. Patients with clinically significant neurological findings had an elevated risk of death at 7 days (odds ratio [OR] 3.58; 95% confidence interval [CI] 1.29; 9.93; p=0.01), but not 30 days. Increasing numbers of clinically significant findings were associated with greater odds of mortality at 7 days (OR 1.70; 95% CI 1.08; 2.67; p=0.02) and 30 days (OR 1.41; 95% CI 1.02; 1.96; p=0.04).

CONCLUSIONS

Imaging patients at the point of admission for VV-ECMO with CT frequently identified clinically significant abnormalities with prognostic implications of these. These findings provide support for the use of more routine CT at the point of treatment escalation with prospective studies now required.

How to Do It: A Safe Bedside Protocol for Dual-Lumen Right Internal Jugular Cannulation for Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients With Severe Acute Respiratory Distress Syndrome

In appropriately selected patients with COVID-19 acute respiratory distress syndrome, venovenous extracorporeal membrane oxygenation (VV ECMO) may offer a promising bridge to lung recovery or lung transplantation if lung recovery fails. Although the cannulation technique for VV ECMO via a right internal jugular (RIJ) dual-lumen catheter (DLC) requires expertise and guidance by either fluoroscopy or transesophageal echocardiography (TEE), it offers theoretical circulatory support advantages by using bicaval venous drainage to deliver oxygenated blood systemically with minimal recirculation as compared with the femoral vein and RIJ dual-site cannula configuration. In addition, patients are often too unstable to transport safely to an operating room or catheterization laboratory, and fluoroscopy is not always readily available to guide RIJ DLC placement. Here, we provide a comprehensive description of a safe, bedside protocol for VV ECMO cannulation via a RIJ DLC under TEE guidance. We will report our center's experience (March 30, 2020 to November 21, 2021) and discuss important hemodynamic, safety, and infection control considerations.

Microaxial Left Ventricular Assist Device in Cardiogenic Shock: A Systematic Review and Meta-Analysis

Microaxial left ventricular assist devices (LVAD) are increasingly used to support patients with cardiogenic shock; however, outcome results are limited to single-center studies, registry data and select reviews. We conducted a systematic review and meta-analysis, searching three databases for relevant studies reporting on microaxial LVAD use in adults with cardiogenic shock. We conducted a random-effects meta-analysis (DerSimonian and Laird) based on short-term mortality (primary outcome), long-term mortality and device complications (secondary outcomes). We assessed the risk of bias and certainty of evidence using the Joanna Briggs Institute and the GRADE approaches, respectively. A total of 63 observational studies (3896 patients), 6 propensity-score matched (PSM) studies and 2 randomized controlled trials (RCTs) were included (384 patients). The pooled short-term mortality from observational studies was 46.5% (95%-CI: 42.7–50.3%); this was 48.9% (95%-CI: 43.8–54.1%) amongst PSM studies and RCTs. The pooled mortality at 90 days, 6 months and 1 year was 41.8%, 51.1% and 54.3%, respectively. Hemolysis and access-site bleeding were the most common complications, each with a pooled incidence of around 20%. The reported mortality rate of microaxial LVADs was not significantly lower than extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumps (IABP). Current evidence does not suggest any mortality benefit when compared to ECMO or IABP.

Limb Ischemia Complications of Veno-Arterial Extracorporeal Membrane Oxygenation

Background

This study aimed to summarize and analyse the risk factors, clinical features, as well as prevention and treatment of limb ischemia complications in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO).

Methods

We retrospectively analyzed 179 adult patients who had undergone V-A ECMO support in the Cardiac Care Unit of the First Hospital of Lanzhou University between March 2019 and December 2021. Patients were divided into the limb ischemia group (LI group) and the non-limb ischemia group (nLI group) according to whether limb ischemia occurred on the ipsilateral side of femoral artery cannulation. In the LI group, patients were salvaged with a distal perfusion cannula (DPC) according to each patient's clinical conditions. The baseline data and ECMO data were compared between the two groups, and risk factors for limb ischemia complications were screened using multiple logistic regression analysis.

Results

Overall, 19 patients (10.6%) had limb ischemia complications, of which 5 (2.8%) were improved after medication adjustment, 12 (8.4%) were salvaged with a DPC, and 2 had undergone surgical intervention. There were significant differences in terms of Extracorporeal Cardiopulmonary Resuscitation (ECPR), Intra-aortic balloon pump (IABP), peak vasoactive-inotropic score (VIS) within 24 h after ECMO (VIS-max), Left ventricular ejection fraction (LVEF), weaning from ECMO, and discharge rate between the two groups. ECPR, IABP, and VIS-max in the LI group were significantly higher than those in the nLI group, whereas weaning from ECMO, discharge rate, and LVEF were significantly lower in the LI group compared to those in the nLI group. Furthermore, multiple logistic regression analysis revealed that diabetes [odds ratio (OR) = 4.338, 95% confidence interval (CI): 1.193–15.772, P = 0.026], IABP (OR = 1.526, 95% CI: 1.038–22.026, P = 0.049) and VIS-max (OR = 1.054, 95% CI: 1.024–1.085, P < 0.001) were independent risk factors for limb ischemia complications in patients who underwent V-A ECMO.

Conclusion

Diabetes, prevalence of IABP and VIS-max value in analyzed groups were independent risk factors for predicting limb ischemia complications in patients who underwent V-A ECMO. The cannulation strategy should be optimized during the establishment of V-A ECMO, and limb ischemia should be systematically evaluated after ECMO establishment. A DPC can be used as a salvage intervention for the complications of critical limb ischemia.

Duplex Analysis of Cannulated Vessels in Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation

Background and objectives: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) cannulas have major repercussions on vascular hemodynamics that can potentially lead to limb ischemia. Duplex ultrasound enables the non-invasive analysis of vascular hemodynamics. This study aims to describe the duplex parameters of the femoral vessels during V-A ECMO support, investigate differences between cannulated and non-cannulated vessels, and analyze the variations in the case of limb ischemia and intra-aortic balloon pumps (IABPs). Methods: Nineteen adults (≥18 years), supported with femoro-femoral V-A ECMO, underwent a duplex analysis of the superficial femoral arteries (SFAs) and veins (FVs). Measured parameters included flow velocities, waveforms, and vessel diameters. Results: 89% of patients had a distal perfusion cannula during duplex analysis and 21% of patients developed limb ischemia. The mean peak systolic flow velocity (PSV) and end-diastolic flow velocity (EDV) of the SFAs on the cannulated side were, respectively, 42.4 and 21.4 cm/s. The SFAs on the non-cannulated side showed a mean PSV and EDV of 87.4 and 19.6 cm/s. All SFAs on the cannulated side had monophasic waveforms, whereas 63% of the SFAs on the non-cannulated side had a multiphasic waveform. Continuous/decreased waveforms were seen in 79% of the FVs on the cannulated side and 61% of the waveforms of the contralateral veins were respirophasic. The mean diameter of the FVs on the cannulated side, in patients who developed limb ischemia, was larger compared to the FVs on the non-cannulated side with a ratio of 1.41 ± 0.12. The group without limb ischemia had a smaller ratio of 1.03 ± 0.25. Conclusions: Femoral cannulas influence flow velocities in the cannulated vessels during V-A ECMO and major waveforms alternations can be seen in all SFAs on the cannulated side and most FVs on the cannulated side. Our data suggest possible venous stasis in the FV on the cannulated side, especially in patients suffering from limb ischemia.

Health-related outcomes of extracorporeal membrane oxygenation in adults: A cross-sectional study

BACKGROUND

Patients with critical illness may face challenges after hospital discharge; therapeutic outcomes of extracorporeal membrane oxygenation (ECMO) are typically measured by survival rate. However, ECMO is an integral part of treatment in critical care medicine, which requires an outcome measure beyond survival. Post-discharge health-related quality of life (HRQoL) is such an indicator.

OBJECTIVES

To measure HRQoL in adult patients who had previously undergone ECMO and explore influential factors related to HRQoL.

METHODS

This cross-sectional descriptive study used a convenience sample of patients discharged between April 2006-April 2016 after at least one month following ECMO. The study was conducted from October 2015 to October 2016, which included data collected from structured questionnaires: the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised and Short-Form Survey-36-v2. Stepwise linear regression determined predictor variables of physical and mental HRQoL.

RESULTS

Age of participants (N = 144) ranged from 24 to 81 years; long-term survival rate was 28.6% after a median follow-up of 1060 days (range = 44-3150 days). Mean scores for physical and mental components of HRQoL were 46.32 and 50.39, respectively. Level of HRQoL was low to moderate. Employment affected all physical components of HRQoL; depression was the main predictor for physical and mental components. Self-perceived health status and anxiety were also factors that influenced HRQoL.

CONCLUSIONS

Variables of employment, self-perceived health status and mental health influenced HRQoL. Early assessment of these factors by healthcare professionals can allow integration of multidimensional interventions following hospital discharge, which could improve HRQoL for patients weaned from ECMO.

The Efficacy of Renal Replacement Therapy for Rewarming of Patients in Severe Accidental Hypothermia-Systematic Review of the Literature

Background: Renal replacement therapy (RRT) can be used to rewarm patients in deep hypothermia. However, there is still no clear evidence for the effectiveness of RRT in this group of patients. This systematic review aims to summarize the rewarming rates during RRT in patients in severe hypothermia, below or equal to 32 °C. Methods: This systematic review was registered in the PROSPERO International Prospective Register of Systematic Reviews (identifier CRD42021232821). We searched Embase, Medline, and Cochrane databases using the keywords hypothermia, renal replacement therapy, hemodialysis, hemofiltration, hemodiafiltration, and their abbreviations. The search included only articles in English with no time limit, up until 30 June 2021. Results: From the 795 revised articles, 18 studies including 21 patients, were selected for the final assessment and data extraction. The mean rate of rewarming calculated for all studies combined was 1.9 °C/h (95% CI 1.5–2.3) and did not differ between continuous (2.0 °C/h; 95% CI 0.9–3.0) and intermittent (1.9 °C/h; 95% CI 1.5–2.3) methods (p > 0.9). Conclusions: Based on the reviewed literature, it is currently not possible to provide high-quality recommendations for RRT use in specific groups of patients in accidental hypothermia. While RRT appears to be a viable rewarming strategy, the choice of rewarming method should always be determined by the specific clinical circumstances, the available resources, and the current resuscitation guidelines.

Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis

BACKGROUND

While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA ECMO, and identify factors associated with survival.

METHODS

We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st June 2021, and included all relevant publications reporting on > 5 adult patients requiring VA ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted.

DATA SYNTHESIS

We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI]: 23.6%-50.1%). Survival among patients with left ventricular ejection fraction (LVEF) < 20% (62.0%, 95%-CI: 51.6%-72.0%) was significantly higher than those with LVEF > 35% (32.1%, 95%-CI: 8.69%-60.7%, p = 0.05). Survival reported in studies from Asia (19.5%, 95%-CI: 13.0%-26.8%) was notably lower than those from Europe (61.0%, 95%-CI: 48.4%-73.0%) and North America (45.5%, 95%-CI: 16.7%-75.8%). GRADE assessment indicated high certainty of evidence for pooled survival.

CONCLUSIONS

When treated with VA ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock without severe left ventricular depression. VA ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

The efficiency of continuous renal replacement therapy for rewarming of patients in accidental hypothermia--An experimental study

Severe accidental hypothermia carries high mortality and morbidity and is often treated with invasive extracorporeal methods. Continuous veno-venous hemodiafiltration (CVVHDF) is widely available in intensive care units. We sought to provide theoretical basis for CVVHDF use in rewarming of hypothermic patients. CVVHDF system was used in the laboratory setting. Heat balance and transferred heat units were evaluated for the system without using blood. We used 5L of crystalloid solution at the temperature of approximately 25°C, placed in a thermally insulated tank (representing the "central compartment" of a hypothermic patient). Time of warming the central compartment from 24.9 to 30.0°C was assessed with different flow combinations: "blood" (central compartment fluid) 50 or 100 or 150 mL/min, dialysate solution 100 or 1500 mL/h, and substitution fluid 0 or 500 mL/h. The total circulation time was 1535 minutes. There were no differences between heat gain values on the filter depending on blood flow (P = .53) or dialysate flow (P = .2). The mean heating time for "blood" flow rates 50, 100, and 150 mL/min was 113.7 minutes (95% CI, 104.9-122.6 minutes), 83.3 minutes (95% CI, 76.2-90.3 minutes), and 74.7 minutes (95% CI, 62.6-86.9 minutes), respectively (P < .01). The respective median rewarming rate for different "blood" flows was 3.6°C/h (IQR, 3.0-4.2°C/h), 4.8 (IQR, 4.2-5.4°C/h), and 5.4 (IQR, 4.8-6.0°C/h), respectively (P < .01). The dialysate flow did not affect the warming rate. Based on our experimental model, CVVHDF may be used for extracorporeal rewarming, with the rewarming rates increasing achieved with higher blood flow rates.

Extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

BACKGROUND

There are several reports of extracorporeal membrane oxygenation (ECMO) use in patients with coronavirus disease 2019 (COVID-19) who develop severe acute respiratory distress syndrome (ARDS). We conducted a systematic review and meta-analysis to guide clinical decision-making and future research.

METHODS

We searched MEDLINE, Embase, Cochrane and Scopus databases from 1 December 2019 to 10 January 2021 for observational studies or randomised clinical trials examining ECMO in adults with COVID-19 ARDS. We performed random-effects meta-analyses and meta-regression, assessed risk of bias using the Joanna Briggs Institute checklist and rated the certainty of evidence using the GRADE approach. Survival outcomes were presented as pooled proportions while continuous outcomes were presented as pooled means, both with corresponding 95% confidence intervals [CIs]. The primary outcome was in-hospital mortality. Secondary outcomes were duration of ECMO therapy and mechanical ventilation, weaning rate from ECMO and complications during ECMO.

RESULTS

We included twenty-two observational studies with 1896 patients in the meta-analysis. Venovenous ECMO was the predominant mode used (98.6%). The pooled in-hospital mortality in COVID-19 patients (22 studies, 1896 patients) supported with ECMO was 37.1% (95% CI 32.3-42.0%, high certainty). Pooled mortality in the venovenous ECMO group was 35.7% (95% CI 30.7-40.7%, high certainty). Meta-regression found that age and ECMO duration were associated with increased mortality. Duration of ECMO support (18 studies, 1844 patients) was 15.1 days (95% CI 13.4-18.7). Weaning from ECMO (17 studies, 1412 patients) was accomplished in 67.6% (95% CI 50.5-82.7%) of patients. There were a total of 1583 ECMO complications reported (18 studies, 1721 patients) and renal complications were the most common.

CONCLUSION

The majority of patients received venovenous ECMO support for COVID-19-related ARDS. In-hospital mortality in patients receiving ECMO support for COVID-19 was 37.1% during the first year of the pandemic, similar to those with non-COVID-19-related ARDS. Increasing age was a risk factor for death. Venovenous ECMO appears to be an effective intervention in selected patients with COVID-19-related ARDS. PROSPERO CRD42020192627.

Complete percutaneous angio-guided approach using preclosing for venoarterial extracorporeal membrane oxygenation implantation and explantation in patients with refractory cardiogenic shock or cardiac arrest

BACKGROUND

The approach for veno-arterial extracorporeal membrane oxygenation implantation (VA-ECMO) in patients with cardiogenic shock can be either surgical or percutaneous. Complete angio-guided percutaneous implantation and explantation could decrease vascular complications. We sought to describe the initial results of complete percutaneous angio-guided ECMO implantation and explantation using preclosing.

METHODS

All consecutive patients who underwent peripheral femoro-femoral VA-ECMO percutaneous implantation for refractory cardiogenic shock or cardiac arrest were enrolled in a prospective registry (03/2018-12/2020). Percutaneous preclosing using two closing devices (Perclose ProGlide, Abbott) inserted before cannulation was used in both femoral artery and vein. Explantation was performed using a crossover technique under angiographic guidance. The occurrence of vascular complication was recorded.

RESULTS

Among the 56 patients who underwent percutaneous VA-ECMO implantation for cardiogenic shock or refractory cardiac arrest, 41 underwent preclosing. Femoral vessel cannulation was successful in all patients and total cannulation time was 20 (10-40) min. Weaning from ECMO was possible in 22/41 patients (54%) and 12 (29%) patients were alive at day 30. Significant vascular complications occurred in 2/41 patients. Percutaneous decannulation was performed in 20 patients with 19/20 technical success rate. All femoral arteries and veins were properly closed using the pre-closing devices without bleeding on the angiographic control except for one patient in whom surgical closure of the artery was required. No patient required transfusion for access related significant bleeding and no other vascular complication occurred. Furthermore, no groin infection was observed after full percutaneous implantation and removal of ECMO.

CONCLUSION

Emergent complete percutaneous angio-guided VA-ECMO implantation and explantation using pre-closing technique can be an attractive strategy in patients referred for refractory cardiogenic shock.