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Simons J, Mees B, MacLaren G, Fraser JF, Zaaqoq AM, Cho SM, Patel BM, Brodie D, Bělohlávek J, Belliato M, Jung JS, Salazar L, Meani P, Mariani S, Di Mauro M, Yannopoulos D, Broman LM, Chen YS, Riera J, van Mook WN, Lorusso R. Evolution of distal limb perfusion management in adult peripheral venoarterial extracorporeal membrane oxygenation with femoral artery cannulation. Perfusion 2024; 39:23S-38S. [PMID: 38651584 DOI: 10.1177/02676591241236650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
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.
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Affiliation(s)
- Jorik Simons
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Barend Mees
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Division of Neuroscience Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bhavesh M Patel
- Department of Critical Care, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jan Bělohlávek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
| | - Mirko Belliato
- SC AR 2 Anestesia e Terapia Intensiva Cardiotoracica, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea
| | - Leonardo Salazar
- Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Paolo Meani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- S. Gerardo Hospital is the hospital of the departmen, Monza, Italy
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Lars Mikael Broman
- Department of Pediatric Perioperative Medicine and Intensive Care, ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jordi Riera
- Department de Medicina Intensiva, Vall d'Hebron Institut de Recerca, SODIR, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Walther Nka van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Edwards J, Stonko DP, Abdou H, Treffalls RN, Walker P, Rasmussen TE, Propper BW, Morrison JJ. Lower Extremity Extracorporeal Distal Revascularization in a Swine Model of Prolonged Extremity Ischemia. Ann Vasc Surg 2023; 89:293-301. [PMID: 36441096 DOI: 10.1016/j.avsg.2022.09.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute arterial occlusion of the lower extremity is a time-dependent emergency that requires prompt revascularization. Lower extremity extracorporeal distal revascularization (LEEDR) is a technique that can be initiated bedside when definitive therapy is delayed. The aim of this study is to evaluate this technique in a swine model of prolonged extremity ischemia. METHODS Anesthetized swine underwent right femoral and left posterior tibial artery cannulation, left iliac venous flow monitoring (mL/min), and continuous left anterior compartment pressure (CP) monitoring (mm Hg). The iliac artery was clamped for 6 hr. LEEDR animals underwent 5 hr of extracorporeal femoral-to-tibial blood flow at 150 mL/min; controls had no intervention. At 6 hr, LEEDR was discontinued, iliac flow restored, and anterior CP monitored for 3 hr. RESULTS Baseline characteristics were similar across both the groups. Iliac clamping saw an expected fall in iliac venous flow (258 ± 30 to 82 ± 19; P < 0.001). LEEDR resulted in a rise in iliac venous flow (82 ± 20 to 181 ± 16; P < 0.001); control arm flow remained reduced (71 ± 8; P < 0.001). Once inflow was restored, venous flow returned to baseline. Revascularization provoked a higher peak CP in the control arm versus in the LEEDR group (25 ± 5 vs. 6 ± 1; P = 0.02). CONCLUSIONS An extracorporeal circuit can temporarily revascularize an extremity in a swine model of prolonged ischemia, mitigating reperfusion injury and maintaining normal CPs. This concept should undergo further evaluation as a bedside tool to mitigate extremity ischemia prior to definitive revascularization.
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Affiliation(s)
- Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - David P Stonko
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | | | - Patrick Walker
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Brandon W Propper
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
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