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Hart JP, Davies MG. Vascular Complications in Extracorporeal Membrane Oxygenation-A Narrative Review. J Clin Med 2024; 13:5170. [PMID: 39274383 PMCID: PMC11396245 DOI: 10.3390/jcm13175170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/21/2024] [Accepted: 08/24/2024] [Indexed: 09/16/2024] Open
Abstract
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.
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Affiliation(s)
- Joseph P Hart
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX 77054, USA
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX 77054, USA
- Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX 76710, USA
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Khedr AM, Foula MS, Alhewy MA, Abdelhafez AA, Hanbal IH, Ghazala EAE, Khamis AA, Gado H, Abd-Elgawad WAA, El Sayed A, Ibrahim A, Elghoneimy Y, Abdelmohsen AA. Acute Vascular Complications of VA-ECMO in COVID-19 Patients. Does COVID-19 Affect the Outcome? Vasc Endovascular Surg 2024:15385744241276650. [PMID: 39196298 DOI: 10.1177/15385744241276650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) through the femoral artery and vein can lead to significant vascular complications. We retrospectively studied the acute vascular complications of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in COVID-19 patients compared to non-COVID patients during the period from January 2020 to July 2023. RESULTS Seventy-eight patients underwent VA-ECMO for various indications from January 2020 to July 2023. The studied patients had a mean age of 59.6 ± 6.9 years for non-COVID patients (38 patients), and 62.2 ± 7.6 years for COVID patients (40 patients), with a P = 0.268. In non-COVID patients, The baseline characteristics were similar in both groups. The primary indications for ECMO were cardiac diseases, followed by respiratory failure (78.9% vs 10.5%). Conversely, in COVID patients, respiratory failure due to COVID-19 infection was the main indication (45% vs 40%). The overall incidence of general complications, including cerebrovascular stroke, acute kidney injury, intracardiac thrombi, and wound infection, was comparable in both groups (31.6% vs 45%). The overall incidence of vascular complications in both groups was 33.3%. Ipsilateral acute lower limb ischemia occurred in 5.3% vs 10% of non-COVID and COVID patients, respectively. Thrombosis of the distal perfusion catheter (DPC) occurred in 10.5% vs 15%, respectively. CONCLUSION During the COVID-19 pandemic, an increasing number of patients required VA-ECMO due to associated respiratory failure. Patients undergoing VA-ECMO are at high risk of developing various vascular complications. COVID-19 significantly increases the risk of acute limb ischemia and distal perfusion catheter thrombosis in both upper and lower limbs. However, other VA-ECMO-related vascular complications are comparable between COVID-19 and non-COVID patients.
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Affiliation(s)
- Alhussein M Khedr
- Vascular and Endovascular Surgery Department, Al-Azhar University, Cairo, Egypt
| | - Mohammed S Foula
- Department of Surgery, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | | | | | | | - Ahmed Atef Khamis
- Vascular and Endovascular Surgery Department, Al-Azhar University, Assiut, Egypt
| | - Hassan Gado
- Vascular and Endovascular Surgery Department, Al-Azhar University, Assiut, Egypt
| | | | - Abdullah El Sayed
- Vascular and Endovascular Surgery Department, Al-Azhar University, Cairo, Egypt
| | - Awad Ibrahim
- Vascular and Endovascular Surgery Department, Faculty of Medicine, Mansura University, Mansoura, Egypt
| | - Yasser Elghoneimy
- Cardiothoracic Surgery Department, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Shin C, Yoo KC, Kim DH. Critical Hemorrhage Caused by a Size-Mismatched Extracorporeal Membrane Oxygenation Cannula in a Patient with Myotonic Dystrophy Type 1: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:969. [PMID: 38929586 PMCID: PMC11205281 DOI: 10.3390/medicina60060969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/07/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Abstract
Background and Objective: Although extracorporeal membrane oxygenation (ECMO) is an essential life-saving technique for patients with refractory cardiopulmonary shock, it can be fatal in certain cases. Case Presentation: A 19-year-old girl treated with ECMO presented with acute limb ischemia 2 days after cannula removal. The decannulation was performed percutaneously by an interventional cardiologist, and the vascular surgery department was consulted after the patient developed symptoms. The first suspected diagnosis was thrombosis due to incorrect use of the closure device. However, the artery had ruptured due to the insertion of a catheter with a cannula that was larger than the patient's artery. Management and Outcome: Fortunately, excessive bleeding due to the size-mismatched cannula was prevented by an unintentional complication of the closing device, which saved the patient's life. She underwent a right common femoral artery thrombectomy and patch angioplasty. Hospital guidelines have changed regarding the surgical removal of ECMO cannulas. Discussion: This report aims to highlight the importance of two aspects that are critical to a successful outcome: individualized cannula selection followed by precise insertion and removal and postoperative evaluation of a patient's final status.
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Affiliation(s)
- Changsik Shin
- Department of Surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu 11759, Republic of Korea
| | - Kwon Cheol Yoo
- Department of Surgery, College of Medicine, Chungbuk National University, Cheongju 28644, Republic of Korea
- Department of Surgery, Chungbuk National University Hospital, Cheongju 28644, Republic of Korea
| | - Dae Hoon Kim
- Department of Surgery, College of Medicine, Chungbuk National University, Cheongju 28644, Republic of Korea
- Department of Surgery, Chungbuk National University Hospital, Cheongju 28644, Republic of Korea
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Davies MG, Hart JP. Current status of ECMO for massive pulmonary embolism. Front Cardiovasc Med 2023; 10:1298686. [PMID: 38179509 PMCID: PMC10764581 DOI: 10.3389/fcvm.2023.1298686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
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.
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Affiliation(s)
- Mark G. Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
- Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX, United States
| | - Joseph P. Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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Dragulescu R, Armoiry X, Jacquet-Lagrèze M, Portran P, Schweizer R, Fellahi JL, Grinberg D, Obadia JF, Pozzi M. Lower Limb Ischemia in Surgical Femoral Veno-Arterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2023; 37:2272-2279. [PMID: 37598037 DOI: 10.1053/j.jvca.2023.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/08/2023] [Accepted: 07/19/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVES To analyze the incidence, clinical impact on survival, and risk factors of lower limb ischemia (LLI) of surgical peripheral femoral venoarterial extracorporeal membrane oxygenation (VA ECMO) in the current era. DESIGN A retrospective analysis of the authors' institutional database of VA ECMO was performed. Patients were divided into 2 groups according to the occurrence of LLI. The primary endpoint was survival to hospital discharge. Risk factors of LLI were searched with multivariate analyses. SETTING University hospital. PARTICIPANTS Adult patients receiving peripheral VA ECMO for refractory cardiogenic shock and cardiac arrest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From January 2018 to December 2021, 188 patients (mean age: 52.0 ± 14.1 years; 63.8% male, 36.2% female) received peripheral VA ECMO. Male sex was more prevalent in the group without LLI (65.9% v 33.3%; p = 0.031). Twelve (6.4%) patients developed LLI during VA ECMO support (n = 6) or after VA ECMO removal (n = 6). Survival to hospital discharge was not statistically different between patients with and without LLI (50.0% v 48.3%; p = 0.571). Female sex patients were at increased risk for LLI (odds ratio 4.38, 95% CI 1.21-15.81; p = 0.024). CONCLUSIONS Peripheral femoral VA ECMO through a surgical approach is associated with a low LLI rate, which does not increase the risk of in-hospital mortality. The female sex is an independent risk factor for LLI.
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Affiliation(s)
- Razvan Dragulescu
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Xavier Armoiry
- University of Lyon, School of Pharmacy (ISPB)/UMR CNRS 5510 MATEIS/"Edouard Herriot" Hospital, Pharmacy Department, Lyon, France
| | | | - Philippe Portran
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Remi Schweizer
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Jean Luc Fellahi
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Daniel Grinberg
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Jean Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France; Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France.
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Rabah H, Rabah A. Extracorporeal Membrane Oxygenation (ECMO): What We Need to Know. Cureus 2022; 14:e26735. [PMID: 35967165 PMCID: PMC9363689 DOI: 10.7759/cureus.26735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 11/05/2022] Open
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Welker C, Huang J, Ramakrishna H. Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support. J Cardiothorac Vasc Anesth 2021; 36:2207-2219. [PMID: 34332842 DOI: 10.1053/j.jvca.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.
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Affiliation(s)
- Carson Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Vascular Complications of Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Regression Analysis. Crit Care Med 2021; 48:e1269-e1277. [PMID: 33105148 DOI: 10.1097/ccm.0000000000004688] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Perform a systematic review and meta-analysis of vascular complications associated with extracorporeal membrane oxygenation and identify prognostic and predictive factors. DATA SOURCES Systematic search for publications reporting vascular complications on extracorporeal membrane oxygenation, published from 1972 to January 31, 2020, was conducted via PubMed, Scopus, and Embase. STUDY SELECTION Of 4,076 references screened, 47 studies with 6,583 patients were included in final analyses. Studies with fewer than 10 patients were excluded. DATA EXTRACTION Relevant data, including demographics, comorbidities, extracorporeal membrane oxygenation and cannulation characteristics, occurrence rates of early and late vascular complications, patient outcomes, and use of distal perfusion cannula, were extracted from selected articles into an excel sheet specifically designed for this review. DATA SYNTHESIS Random-effects meta-analyses and meta-regression analyses were undertaken. Overall pooled estimate of vascular complications in our meta-analysis was 29.5% (95% CI, 23.6-35.9%). Two-thousand three-hundred forty-seven vascular complications in 6,124 venoarterial extracorporeal membrane oxygenation patients compared with 95 in 459 venovenous extracorporeal membrane oxygenation patients (odds ratio, 2.35; 95% CI, 1.87-2.96; p < 0.0001) were analyzed. Successful weaning off extracorporeal membrane oxygenation occurred in 60.6% of pooled patients; 46.2% were eventually discharged. Pooled prevalences of vascular complications like significant bleeding, limb ischemia, and cannula site bleeding were 15.4% (95% CI, 8.6-23.7%), 12.6% (95% CI, 10.0-15.5%), and 12.6% (95% CI, 9.6-18.5%), respectively. Meta-analysis showed that the use of distal perfusion cannula was associated with lower odds of limb ischemia (odds ratio, 1.93; 95% CI, 1.17-2.47; p = 0.03) Meta-regression showed that male sex, smoking, advanced age, and comorbidities contributed to higher in-hospital mortality, while distal perfusion cannula was protective. CONCLUSIONS Nearly a third of patients on extracorporeal membrane oxygenation develop vascular complications; elderly males with comorbidities appear vulnerable. The use of distal perfusion cannulas caused significant reduction in limb ischemia and mortality.
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Abstract
BACKGROUND Factors influencing the quality of end-of-life communication are relevant to improving end-of-life care. We assessed the quality of end-of-life communication and influencing factors in 2 intensive care unit (ICU) cohorts at high risk of death: patients living in nursing homes and those on extracorporeal membrane oxygenation (ECMO). METHODS This retrospective cohort study included admissions to 4 ICUs in Winnipeg, Manitoba, from 2000 to 2017. We identified cohorts and influencing factors from the Winnipeg ICU database and by manual chart review. We assessed quality of end-of-life communication using 18 validated, binary quality indicators to calculate a weighted, scaled, composite score (range 0-100). We used median regression to identify factors associated with the composite score. RESULTS The ECMO cohort (n = 109) was younger than the nursing home cohort (n = 230), with longer hospital stays and higher disease severity. Mean composite scores of end-of-life communication were extremely low in both cohorts (mean 48.5 [standard error of the mean (SEM) 1.7] for the nursing home cohort, 49.1 [SEM 2.5] for the ECMO cohort). Patient characteristics associated with higher median composite scores were older age (5.0 per decade, 95% confidence interval [CI] 2.1-7.8) and lower (worse) Glasgow Coma Scale (GCS) scores (1.8 per GCS point, 95% CI 0.5-3.2). The median composite score rose significantly over time (1.7 per year, 95% CI 0.5-2.8). INTERPRETATION The quality of end-of-life communication in ICUs is poor, and factors associated with better prognosis are also associated with worse communication. Direct and early communication should occur with all patients in the ICU and their surrogates, not just those who are believed most likely to die.
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Affiliation(s)
- Tammy L Pham
- Physician Assistant Education Program (Pham), University of Manitoba; Winnipeg Regional Health Authority (Pham); Departments of Internal Medicine and Community Health Sciences (Garland), University of Manitoba, Winnipeg, Man.
| | - Allan Garland
- Physician Assistant Education Program (Pham), University of Manitoba; Winnipeg Regional Health Authority (Pham); Departments of Internal Medicine and Community Health Sciences (Garland), University of Manitoba, Winnipeg, Man
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg 2021; 161:1287-1331. [PMID: 33039139 DOI: 10.1016/j.jtcvs.2020.09.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md.
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Department of Anaesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Wash
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Ashish Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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Acute vascular complications of femoral veno-arterial ECMO: a single-centre retrospective study. Egypt Heart J 2021; 73:15. [PMID: 33606143 PMCID: PMC7892760 DOI: 10.1186/s43044-021-00143-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Femoral arterial cannulation to initiate veno-arterial ECMO may result in ipsilateral limb ischemia due to reduced distal blood flow below the insertion point of the cannula. We retrospectively studied adult patients supported with femoral VA-ECMO for cardiogenic shock between 2015 and 2019 at our tertiary care hospital. Results The study included 65 adult patients supported with femoral VA-ECMO for refractory cardiogenic shock. The studied patients had a mean age of 37.9 ± 14.87 years, mostly males (70.8%), a mean BSA of 1.77 ± 0.27 m2, and a mean BMI of 26.1 ± 6.7 kg/m2. Twenty-one (32.3%) patients developed acute lower limb ischemia. The patients who developed acute limb ischemia had significantly frequent AKI (< 0.001) without significant use of haemodialysis (p = 0.07) and longer ICU stay (p = 0.028) compared to the patients without limb ischemia. The hospital mortality occurred in 29 (44.6%) patients without significant difference between the patients with and without acute limb ischemia. The occurrence of acute limb ischemia was significantly correlated with failed percutaneous cannulation (p = 0.039), while there was no significant statistical correlation between the cut-down technique and occurrence of limb ischemia (p = 0.053). The occurrence of femoral cannulation site bleeding was significantly correlated with failed percutaneous cannulation (p = 0.001) and cut-down technique (p = 0.001). Conclusion Acute vascular complications are frequent after femoral VA-ECMO. Failed percutaneous femoral cannulation has been, in this study, identified as the most important risk factor for acute limb ischemia and cannulation site bleeding. A careful approach during femoral cannulation is recommended to prevent occurrence of acute limb ischemia and femoral cannulation site bleeding.
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Pisani A, Braham W, Brega C, Lajmi M, Provenchere S, Danial P, Alkhoder S, Para M, Ghodbane W, Nataf P. Right axillary artery cannulation for venoarterial extracorporeal membrane oxygenation: a retrospective single centre observational study. Eur J Cardiothorac Surg 2020; 59:601-609. [DOI: 10.1093/ejcts/ezaa397] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/03/2020] [Accepted: 09/11/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Our goal was to assess the safety, outcomes and complication rate of axillary artery cannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO).
METHODS
A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients undergoing VA-ECMO implantation between January 2013 and December 2017 at a teaching hospital. Only patients with right axillary VA-ECMO implantation in a non-emergency setting were included. Post-procedural outcomes and local and systemic complications were analysed.
RESULTS
One hundred and seventy-four [131 male (75.3%), 43 female (24.7%); mean age 56.8 ± 15.1 years] patients underwent femoral-axillary VA-ECMO. Indications were cardiogenic shock from any cause (n = 78, 44.8%) or post-cardiotomy syndrome (n = 96, 55.2%). Fifty-three (30.5%) patients died while on VA-ECMO support. At the time of VA-ECMO ablation, 89 (51.1%) patients had recovered; 13 (7.5%) patients were bridged to a long-term mechanical support device and 19 (10.9%) patients underwent heart transplants. Thirty-day and 1-year mortality was 36.2% (n = 63) and 49.4% (n = 86), respectively. The 1-year survival rate of patients who were weaned from VA-ECMO support was 72.7% (n = 88). The complications of axillary cannulation were bleeding (n = 7, 4%), local infection (n = 3, 1.7%), upper limb ischaemia (n = 2, 1.1%) and brachial plexus injury (n = 1, 0.6%). Left ventricle unloading was required for 9 (5.2%) patients. The median duration of VA-ECMO support was 7 (range 1–26) days.
CONCLUSIONS
Right axillary artery cannulation is a safe and reliable method for VA-ECMO support with a low rate of local complications. In the absence of a control group with femoro-femoral cannulation, no definitive conclusion about the superiority of axillary over femoral cannulation can be drawn.
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Affiliation(s)
- Angelo Pisani
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Wael Braham
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Carlotta Brega
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Ravenna, Italy
| | - Moklhes Lajmi
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Sophie Provenchere
- Department of Anesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
- Université de Paris, Centre d'Investigation Clinique 1425, INSERM, Paris, France
| | - Pichoy Danial
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Soleiman Alkhoder
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Marylou Para
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
- Université de Paris, LVTS UMRS 1148, INSERM, Paris, France
| | - Walid Ghodbane
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Patrick Nataf
- Department of Cardiovascular Surgery, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D’Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2020; 59:12-53. [DOI: 10.1093/ejcts/ezaa283] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D’Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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15
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients. Ann Thorac Surg 2020; 111:327-369. [PMID: 33036737 DOI: 10.1016/j.athoracsur.2020.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Center, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Glenn Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Milan Milojevic
- Department of Anesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Washington
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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16
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Zheng L, Kim P, Shin J, Lim J, Ko H, Gwon D, Ko GY, Li H. Interventional treatment of bleeding complications due to percutaneous cannulation for peripheral extracorporeal membrane oxygenation. Diagn Interv Imaging 2019; 100:337-345. [DOI: 10.1016/j.diii.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 02/06/2023]
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18
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Lo Coco V, Lorusso R, Raffa GM, Malvindi PG, Pilato M, Martucci G, Arcadipane A, Zieliński K, Suwalski P, Kowalewski M. Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille's heel. J Thorac Dis 2018; 10:6993-7004. [PMID: 30746245 DOI: 10.21037/jtd.2018.11.103] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is life-saving for potentially reversible heart failure and respiratory injuries not responsive to conventional therapies. Technological innovations have produced over the years significant improvements in ECMO devices (pump, cannula design and oxygenator) and have allowed a better risk/benefit profile. Alongside with recognized advantages in the treatment of very sick patients, ECMO remains an invasive procedure for mechanical circulatory support (MCS) and it is associated with complications that strongly influence the prognosis. Current review was designed to provide a comprehensive outline on ECMO complications, analyzing risk factors and strategies of management, focusing on adult population undergoing veno-arterial ECMO (VA-ECMO) therapy.
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Affiliation(s)
- Valeria Lo Coco
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe M Raffa
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | | | - Michele Pilato
- Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Gennaro Martucci
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | | | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Clinical Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland
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19
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Comparing Percutaneous to Open Access for Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure. Pediatr Crit Care Med 2018; 19:981-991. [PMID: 30080776 PMCID: PMC6173194 DOI: 10.1097/pcc.0000000000001691] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluate trends in method of access (percutaneous cannulation vs open cannulation) for pediatric extracorporeal membrane oxygenation and determine the effects of cannulation method on morbidity and mortality. DESIGN Retrospective cohort study. SETTING AND SUBJECTS The Extracorporeal Life Support Organization's registry was queried for pediatric patients on extracorporeal membrane oxygenation for respiratory failure from 2007 to 2015. INVERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 3,501 patients identified, 77.2% underwent open cannulation, with the frequency of open cannulation decreasing over the study period from approximately 80% to 70% (p < 0.001). Percutaneous cannulation patients were more commonly male (24.2% vs 21.5%; p = 0.01), older (average 7.6 vs 4.5 yr; p < 0.001), and heavier (average 33.0 vs 20.2 kg; p < 0.001). Subset analysis of patients on venovenous extracorporeal membrane oxygenation revealed higher rates of mechanical complications due to blood clots (28.9% vs 22.6%; p = 0.003) or cannula problems (18.9% vs 12.7%; p < 0.001), cannula site bleeding (25.3% vs 20.2%; p = 0.01) and increased rates of cannula site repair in the open cannulation cohort. Limb related complications were not significantly different on subset analysis for venovenous extracorporeal membrane oxygenation patients stratified by access site. Logistic regression analysis revealed that method of access was not associated with a difference in mortality. CONCLUSIONS The proportion of pediatric patients undergoing percutaneous extracorporeal membrane oxygenation cannulation is increasing. Mechanical and physiologic complications occur with both methods of cannulation, but percutaneous cannulation appears safe in this cohort. Further analysis is needed to evaluate long-term outcomes with this technique.
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20
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Elmously A, Bobka T, Khin S, Afzal A, de Biasi AR, DeBois WJ, Guy TS, D'ayala M, Gulkarov I, Salemi A, Worku B. Distal Perfusion Cannulation and Limb Complications in Venoarterial Extracorporeal Membrane Oxygenation. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2018; 50:155-160. [PMID: 30250341 PMCID: PMC6146267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 05/28/2018] [Indexed: 06/08/2023]
Abstract
The utility of distal perfusion cannula (DPC) placement for the prevention of limb complications in patients undergoing femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is poorly characterized. Patients undergoing femoral VA ECMO cannulation at two institutions were retrospectively assessed. Patients were grouped into those who did and those who did not receive a DPC at the time of primary cannulation. The primary outcome was any limb complication. Secondary outcomes included successfully weaning ECMO and in-hospital mortality. A total of 75 patients underwent femoral cannulation between December 2010 and December 2017. Of those, 65 patients (86.7%) had a DPC placed during primary cannulation and 10 patients (13.3%) did not. Baseline demographics, indications for ECMO, and hemodynamic perturbations were well matched between groups. The rate of limb complications was 14.7% (11/75) for the overall cohort and did not differ between groups (p = .6). Three patients (4%) required a four-compartment fasciotomy for compartment syndrome in the DPC group; no patients without a DPC required fasciotomy. Of the three patients who required a thrombectomy for distal ischemia, two were in the DPC group and one was in the no-DPC group (p = .3). Two patients (2.7%) underwent delayed DPC placement for limb ischemia with resolution of symptoms. The in-hospital morality rate was 59.5% and did not differ between groups (p = .5). Patients in the present study, undergoing femoral VA ECMO without preemptive DPC placement did not experience a higher rate of limb complications. However, the two patients who underwent delayed DPC placement for post-cannulation ischemia experienced resolution of symptoms, suggesting that a DPC may be used as an effective limb salvage intervention.
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Affiliation(s)
- Adham Elmously
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Thomas Bobka
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Sandi Khin
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Ashwad Afzal
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Andreas R de Biasi
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - William J DeBois
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - T Sloane Guy
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Marcus D'ayala
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Iosif Gulkarov
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Arash Salemi
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
| | - Berhane Worku
- New York Presbyterian Hospital-Weill Cornell Medicine, New York Presbyterian Hospital-Brooklyn Methodist, New York, New York
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21
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Yang F, Hou D, Wang J, Cui Y, Wang X, Xing Z, Jiang C, Hao X, Du Z, Yang X, Jiang Y, Hou X. Vascular complications in adult postcardiotomy cardiogenic shock patients receiving venoarterial extracorporeal membrane oxygenation. Ann Intensive Care 2018; 8:72. [PMID: 29916091 PMCID: PMC6006001 DOI: 10.1186/s13613-018-0417-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 06/11/2018] [Indexed: 01/12/2023] Open
Abstract
Background The rate, prognostic impacts, and predisposing factors of major vascular complications (MVCs) in patients underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO) by surgical cut-down are poorly understood. The purpose of this study was to identify these parameters in adult VA-ECMO patients. Methods Adult postcardiotomy cardiogenic shock (PCS) patients receiving VA-ECMO by femoral surgical cut-down cannulation from January 2004 to December 2015 were enrolled in this study. Patients were separated into two groups depending on the presence of MVCs. Multivariate logistic regression was performed to identify factors independently associated with MVCs. Results Of 432 patients with PCS treated with VA-ECMO, 252 patients (58.3%) were weaned off VA-ECMO and 153 patients (35.4%) survived to discharge. MVCs were seen in 72 patients (16.7%), including bleeding or hematoma in the cannulation site (8.6%), limb ischemia requiring fasciotomy (8.6%), femoral artery embolism (0.7%), and retroperitoneal bleeding (0.7%). The rate of survival to discharge was 16.7 and 39.2% in patients with or without MVCs, respectively (p < 0.001). Obesity, concomitant with intra-aortic balloon pump (IABP), Sequential Organ Failure Assessment (SOFA) score at 24 h post-ECMO, and hemostasis disorder were shown to be associated with MVCs. MVCs were an independent risk factor for in-hospital mortality by multivariate analysis (odds ratio 3.91; 95% confidence interval, 1.67–9.14; p = 0.013). Conclusions MVCs are common and associated with higher in-hospital mortality among adult PCS patients receiving peripheral VA-ECMO support. The obesity, concomitant with IABP, SOFA score at 24 h post-ECMO, and hemostasis disorder were independent risk factor of MVCs.
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Affiliation(s)
- Feng Yang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Dengbang Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Jinhong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Yongchao Cui
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Zhichen Xing
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Chunjing Jiang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Xiaofang Yang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Yu Jiang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, Chaoyang District, Beijing, 100029, China.
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22
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Pillai AK, Bhatti Z, Bosserman AJ, Mathew MC, Vaidehi K, Kalva SP. Management of vascular complications of extra-corporeal membrane oxygenation. Cardiovasc Diagn Ther 2018; 8:372-377. [PMID: 30057883 DOI: 10.21037/cdt.2018.01.11] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extra-corporeal membrane oxygenation (ECMO) is a well-established treatment for cardiopulmonary failure. Based on the requirement for cardiac and or respiratory support different configurations of ECMO circuits are utilized. Vascular complication of ECMO constitutes the most important determinant of treatment outcomes. The complications are primarily related to limb ischemia, vascular injury, hemorrhage, and infection. Endovascular and surgical treatment options are the cornerstone for managing vascular complications of ECMO.
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Affiliation(s)
- Anil K Pillai
- Health Science Center, University of Texas, Houston, USA
| | - Zagum Bhatti
- Health Science Center, University of Texas, Houston, USA
| | | | - Manoj C Mathew
- Health Science Center, University of Texas, Houston, USA
| | - Kaza Vaidehi
- Southwestern Medical Center, University of Texas, Houston, USA
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23
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Ghodsizad A, Lai CM, Grant AA, Mendoza C, Loebe M, Koerner MM, Badiye A. Endovascular crossover perfusion of lower limb in patients supported on venoarterial extracorporeal membrane oxygenation: Rescue therapy or thoughtful approach? J Thorac Cardiovasc Surg 2018; 156:168-170. [PMID: 29921093 DOI: 10.1016/j.jtcvs.2018.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/05/2017] [Accepted: 01/06/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Ali Ghodsizad
- Miami Transplant Institute, Miami, Fla; Division of Cardiothoracic Surgery, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla.
| | - Cynthia M Lai
- Miami Transplant Institute, Miami, Fla; Division of Cardiothoracic Surgery, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla
| | - April A Grant
- Division of Trauma and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla
| | - Cesar Mendoza
- Division of Cardiology, Department of Medicine, Leonard M. Miller School of Medicine, Miami, Fla
| | - Matthias Loebe
- Miami Transplant Institute, Miami, Fla; Division of Cardiothoracic Surgery, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fla
| | | | - Amit Badiye
- Division of Cardiology, Department of Medicine, Leonard M. Miller School of Medicine, Miami, Fla
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García-Gigorro R, Renes-Carreño E, Pérez-Vela J, Marín-Mateos H, Gutiérrez J, Corrés-Peiretti M, Delgado J, Pérez-de la Sota E, Cortina-Romero J, Montejo-González J. Soporte mecánico con membrana de oxigenación extracorpórea veno-arterial (ECMO-VA): evolución a corto y a largo plazo tras la retirada de la asistencia. Med Intensiva 2017; 41:513-522. [DOI: 10.1016/j.medin.2016.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/06/2016] [Accepted: 12/27/2016] [Indexed: 11/26/2022]
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25
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26
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Nuffer Z, Rupasov A, Bekal N, Murtha J, Bhatt S. Spectral Doppler ultrasound of peripheral arteries: a pictorial review. Clin Imaging 2017; 46:91-97. [PMID: 28755582 DOI: 10.1016/j.clinimag.2017.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/26/2017] [Accepted: 07/10/2017] [Indexed: 11/18/2022]
Abstract
This article reviews the pathophysiology and sonographic findings of peripheral arterial lesions, with emphasis on the spectral Doppler waveforms encountered in each. It discusses the characteristic features of the Doppler spectra in obstructive conditions, including thromboembolism, atherosclerotic disease, bypass graft occlusion, dissection, trauma, and compartment syndrome, as well as non-obstructive conditions, including hyperemia, pseudoaneurysm, and arteriovenous fistula. Familiarity with the commonly-encountered spectral waveforms in the setting of these lesions is necessary for timely and accurate diagnosis and treatment.
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Affiliation(s)
- Zachary Nuffer
- Diagnostic Radiology Resident, University of Rochester Medical Center, 601 Elmwood Avenue, Box 648, Rochester, NY 14642, United States.
| | - Andrey Rupasov
- Diagnostic Radiology Resident, University of Rochester Medical Center, 601 Elmwood Avenue, Box 648, Rochester, NY 14642, United States
| | - Neel Bekal
- Preliminary Medicine Intern, Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
| | - Jacqueline Murtha
- Medical Student, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 648, Rochester, NY 14642, United States
| | - Shweta Bhatt
- Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Avenue, Box 648, Rochester, NY 14642, United States
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Khorsandi M, Dougherty S, Bouamra O, Pai V, Curry P, Tsui S, Clark S, Westaby S, Al-Attar N, Zamvar V. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg 2017; 12:55. [PMID: 28716039 PMCID: PMC5512816 DOI: 10.1186/s13019-017-0618-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/10/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint. METHODS A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API). RESULTS We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I 2 = 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported. CONCLUSION Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK.
| | | | - Omar Bouamra
- Medical Statistics, Trauma, Audit & Research Network, University of Manchester, Salford Royal NHS foundation trust, Manchester, UK
| | - Vasudev Pai
- Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College, Manipal University, Manipal, India
| | - Philip Curry
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Steven Tsui
- Department of Cardiac Surgery and Transplantation, Papworth hospital, Cambridge, UK
| | - Stephen Clark
- Department of Cardiac surgery and Transplantation, Freeman hospital, Newcastle, UK
| | - Stephen Westaby
- Department of Cardiac Surgery, Oxford Heart Center, John Radcliffe Hospital, Oxford, UK
| | - Nawwar Al-Attar
- Department of Cardiac Surgery and Transplantation, Golden Jubilee National Hospital, Glasgow, UK
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Advanced Age as a Predictor of Survival and Weaning in Venoarterial Extracorporeal Oxygenation: A Retrospective Observational Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3505784. [PMID: 28484710 PMCID: PMC5397620 DOI: 10.1155/2017/3505784] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/16/2017] [Accepted: 03/07/2017] [Indexed: 02/07/2023]
Abstract
Background. In most reports on ECMO treatment, advanced age is classified as a contraindication to VA ECMO. We attempted to investigate whether advanced age would be a main risk factor deciding VA ECMO application and performing VA ECMO support. We determined whether advanced age should be regarded as an absolute or relative contraindication to VA ECMO and could affect weaning and survival rates of VA ECMO patients. Methods. VA ECMO was performed on 135 adult patients with primary cardiogenic shock between January 2010 and December 2014. Successful weaning was defined as weaning from ECMO followed by survival for more than 48 hours. Results. Among the 135 patients, 35 survived and were discharged uneventfully, and the remaining 100 did not survive. There were significant differences in survival between age groups, and older age showed a lower survival rate with statistical significance (P = .01). By multivariate logistic regression analysis, age was not significantly associated with in-hospital mortality (P = .83) and was not significantly associated with VA ECMO weaning (P = .11). Conclusions. Advanced age is an undeniable risk factor for VA ECMO; however, patients of advanced age should not be excluded from the chance of recovery after VA ECMO treatment.
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Makdisi G, Makdisi T, Wang IW. Use of distal perfusion in peripheral extracorporeal membrane oxygenation. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:103. [PMID: 28361068 DOI: 10.21037/atm.2017.03.01] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extra corporeal membrane oxygenation (ECMO) is a life-saving technique to manage refractory cardiopulmonary failure. Its usage and indication continue to increase. Femoral venoarterial ECMO (VA ECMO) is relatively less invasive and the cardiac support may be more rapidly instituted in in these extremely tenuous patients. Vascular injuries and limb ischemia unfortunately occur in these emergent access settings. Here we will discuss the optimal techniques of preventing this complication which might affect patient survival and impact the patient quality of life.
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Affiliation(s)
- George Makdisi
- Division of cardiothoracic surgery, Tampa General Hospital, Tampa, FL, USA
| | - Tony Makdisi
- Palliative care division, University of Massachusetts Medical School, Berkshire Medical Center, Pittsfield, MA, USA
| | - I-Wen Wang
- Indiana University School of Medicine, Division of Cardiothoracic Surgery, Indiana University Health, Methodist Hospital, Indianapolis, IN, USA
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Cho YS, Song KH, Lee BK, Jeung KW, Jung YH, Lee DH, Lee SM. Five-year Experience of Extracorporeal Life Support in Emergency Physicians. Korean J Crit Care Med 2017; 32:52-59. [PMID: 31723616 PMCID: PMC6786739 DOI: 10.4266/kjccm.2016.00885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/19/2016] [Accepted: 02/09/2017] [Indexed: 01/01/2023] Open
Abstract
Background This study aimed to present our 5-year experience of extracorporeal cardiopulmonary resuscitation (ECPR) performed by emergency physicians. Methods We retrospectively analyzed 58 patients who underwent ECPR between January 2010 and December 2014. The primary parameter analyzed was survival to hospital discharge. The secondary parameters analyzed were neurologic outcome at hospital discharge, cannulation time, and ECPR-related complications. Results Thirty-one patients (53.4%) were successfully weaned from extracorporeal membrane oxygenation, and 18 (31.0%) survived to hospital discharge. Twelve patients (20.7%) were discharged with good neurologic outcomes. The median cannulation time was 25.0 min (interquartile range 20.0-31.0 min). Nineteen patients (32.8%) had ECPR-related complications, the most frequent being distal limb ischemia. Regarding the initial presentation, 52 patients (83.9%) collapsed due to a cardiac etiology, and acute myocardial infarction (33/62, 53.2%) was the most common cause of cardiac arrest. Conclusions The survival to hospital discharge rate for cardiac arrest patients who underwent ECPR conducted by an emergency physician was within the acceptable limits. The cannulation time and complications following ECPR were comparable to those found in previous studies.
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Affiliation(s)
- Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | | | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung Min Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
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Hryniewicz K, Sandoval Y, Samara M, Bennett M, Cabuay B, Chavez IJ, Seatter S, Eckman P, Zimbwa P, Dunn A, Sun B. Percutaneous Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock Is Associated with Improved Short- and Long-Term Survival. ASAIO J 2016; 62:397-402. [DOI: 10.1097/mat.0000000000000378] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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On-site ECMO in the cardiac intensive care unit. A new tool to improve advanced cardiopulmonary resuscitation. Int J Cardiol 2016; 207:3-5. [DOI: 10.1016/j.ijcard.2016.01.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/03/2016] [Indexed: 11/21/2022]
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Ma RWL, Huilgol RL, Granger E, Jackson A, Saling S, Dower A, Nivison-Smith I. Does a distal perfusion cannula reduce ischaemic complications of extracorporeal membrane oxygenation? ANZ J Surg 2016; 86:1002-1006. [PMID: 26923903 DOI: 10.1111/ans.13441] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides support to patients with severe but reversible cardiac or pulmonary failure. Vascular complications of ECMO are well recognized. METHODS We performed a retrospective review of 70 patients (mean age 48 years; 15-85) who received peripheral veno-arterial ECMO from 2004 to 2010 in a single centre. For statistical analysis, chi-squared test and multivariate binary logistic regression analysis were used to assess for association between response variables (i.e. limb ischaemia, ECMO site bleeding and deep vein thrombosis (DVT)) and possible predictive variables. RESULTS There were 14 (20%) cases of acute limb ischaemia with no statistically significant relationship between acute limb ischaemia and independent variables. Thirty-three patients received distal limb cannulas (47%). There was no statistically significant association between limb ischaemia and presence of distal limb cannula (P = 0.8). Multivariate binary logistic regression analysis identified insertion by cutdown as a predictor of lower probability of insertion site bleeding (n = 12, odds ratio 0.24, P = 0.04). Seven cases of DVT were identified; multivariate binary logistic regression analysis identified insertion by cutdown (odds ratio 0.08, P = 0.03) and days of ECMO less than five (odds ratio 0.08, P = 0.04) as predictive factors for reduced rates of DVT. CONCLUSION Ischaemic complications of ECMO are common and occur despite the presence of a distal limb-perfusing cannula; however in our study the distal limb cannula was a limb-salvaging intervention in six patients. Prolonged time on ECMO is a risk factor for DVT, and a high index of suspicion must be maintained. Percutaneous insertion was associated with higher rates of bleeding and DVT.
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Affiliation(s)
- Robert Wai-Leung Ma
- St Vincent's Hospital Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ravi L Huilgol
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia.,St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Emily Granger
- St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Andrew Jackson
- St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Samantha Saling
- St Vincent's Hospital Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ashraf Dower
- St Vincent's Hospital Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Kim KI, Lee HS, Kim HS, Ha SO, Lee WY, Park SJ, Lee SH, Lee TH, Seo JY, Choi HH, Park KT, Han SJ, Hong KS, Hwang SM, Lee JJ. The pre-ECMO simplified acute physiology score II as a predictor for mortality in patients with initiation ECMO support at the emergency department for acute circulatory and/or respiratory failure: a retrospective study. Scand J Trauma Resusc Emerg Med 2015; 23:59. [PMID: 26283075 PMCID: PMC4538750 DOI: 10.1186/s13049-015-0135-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022] Open
Abstract
Background In the emergency department (ED), extracorporeal membrane oxygenation (ECMO) can be used as a rescue treatment modality for patients with refractory circulatory and/or respiratory failure. Serious consideration must be given to the indication, and the PRESERVE and RESP scores for mortality have been investigated. However these scores were validated to predict survival in patients who received mainly veno-venous (VV) ECMO in the intensive care unit. The aim of the present study was to investigate the factors that predicted the outcomes for patients who received mixed mode (veno-arterial [VA] and VV) ECMO support in the ED. Methods This single center retrospective study included 65 patients who received ECMO support at the ED for circulatory or respiratory failure between January 2009 and December 2013. Pre-ECMO SAPS II and other variables were evaluated and compared for predicting mortality. Results Fifty-four percent of patients received ECMO-cardiopulmonary resuscitation (E-CPR), 31 % received VA and V-AV ECMO, and 15 % received VV ECMO. The 28-day and 60-month mortality rates were 52 % and 63 %. In the multivariate analysis, only the pre-ECMO Simplified Acute Physiology Score II (SAPS II) (odd ratio: 1.189, 95 % confidence interval: 1.032–1.370, p = 0.016) could predict the 28-day mortality. The area under the receiver operating characteristic curve and the optimal cutoff value for pre-ECMO SAPS II in predicting 28-day mortality was 0.852 (95 % CI: 0.753–0.951, p < 0.001) and 80 (sensitivity of 97.1 % and specificity of 71.0 %), respectively. Validation of the 80 cutoff value revealed a statistically significant difference for the 28-day and 60-month mortality rates in the overall, E-CPR, and VA groups (28-day: p < 0.001, p = 0.004, p = 0.005; 60-month: p < 0.001, p = 0.004, p = 0.020). In the Kaplan-Meier analysis, the 28-day and 60-month survival rates were lower among the patients with a pre-ECMO SAPS II of ≤80, compared to those with a score of >80 (both, p < 0.001). Conclusion The pre-ECMO SAPS II could be helpful for identifying patients with refractory acute circulatory and/or respiratory failure who will respond to ECMO support in the ED.
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Affiliation(s)
- Kun Il Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Donan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea.
| | - Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Donan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea.
| | - Hyoung Soo Kim
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University, Chuncheon, South Korea.
| | - Won Yong Lee
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sang Jun Park
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sun Hee Lee
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Tae Hun Lee
- Division of Cardiology, Department of Internal Medicine, Hallym University, Chuncheon, South Korea.
| | - Jeong Yeol Seo
- Division of Cardiology, Department of Internal Medicine, Hallym University, Chuncheon, South Korea.
| | - Hyun Hee Choi
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Kyu Tae Park
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Sang Jin Han
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Kyung Soon Hong
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Sung Mi Hwang
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Jae Jun Lee
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
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Díez F, Sousa I, Juárez M, Díez-Villanueva P, Elízaga J, Fernández-Avilés F. Resucitación cardiopulmonar mediante ECMO percutáneo: una nueva herramienta en el laboratorio de hemodinámica. Med Intensiva 2015; 39:251-3. [DOI: 10.1016/j.medin.2014.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 03/05/2014] [Accepted: 04/04/2014] [Indexed: 11/29/2022]
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Schaheen BW, Thiele RH, Isbell JM. Extracorporeal life support for adult cardiopulmonary failure. Best Pract Res Clin Anaesthesiol 2015; 29:229-39. [PMID: 26060032 DOI: 10.1016/j.bpa.2015.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 01/19/2023]
Abstract
The use of extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO), as it is also known, has rapidly expanded over the past decade. The increase in ECMO use is a consequence of multiple factors including significant advancements in extracorporeal technology, the emergence of data supporting its use, and a growing number of potential clinical applications. This review focuses on the various modes of ECLS as well as the clinical indications and available evidence for the use of extracorporeal support.
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Affiliation(s)
- Basil W Schaheen
- General Surgery, University of Virginia, P.O. Box 800681, Charlottesville, VA 22908, USA.
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908-0710, USA.
| | - James M Isbell
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, P.O. Box 800679, Charlottesville, VA 22908, USA.
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Ohman JW, Vemuri C, Prasad S, Silvestry SC, Jim J, Geraghty PJ. The effect of extremity vascular complications on the outcomes of cardiac support device recipients. J Vasc Surg 2014; 59:1622-7. [DOI: 10.1016/j.jvs.2013.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 12/06/2013] [Accepted: 12/06/2013] [Indexed: 11/29/2022]
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Roussel A, Al-Attar N, Khaliel F, Alkhoder S, Raffoul R, Alfayyadh F, Rigolet M, Nataf P. Arterial vascular complications in peripheral extracorporeal membrane oxygenation support: a review of techniques and outcomes. Future Cardiol 2014; 9:489-95. [PMID: 23834690 DOI: 10.2217/fca.13.34] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Arnaud Roussel
- Department of Cardiac Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Benassi F, Vezzani A, Vignali L, Gherli T. Ultrasound Guided Femoral Cannulation and Percutaneous Perfusion of the Distal Limb for VA ECMO. J Card Surg 2014; 29:427-9. [DOI: 10.1111/jocs.12319] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Filippo Benassi
- Cardiac Surgery Unit; Azienda Ospedaliero-Universitaria di Parma; Parma Italy
| | - Antonella Vezzani
- Cardiac Surgery Unit; Azienda Ospedaliero-Universitaria di Parma; Parma Italy
| | - Luigi Vignali
- Cardiology Unit; Azienda Ospedaliero-Universitaria di Parma; Parma Italy
| | - Tiziano Gherli
- Cardiac Surgery Unit; Azienda Ospedaliero-Universitaria di Parma; Parma Italy
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Al-Attar N, Bouadma L, Altaani H, Wolff M, Nataf P. Successful management of life-threatening respiratory failure from H1N1 influenza. World J Respirol 2013; 3:8-10. [DOI: 10.5320/wjr.v3.i1.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/10/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023] Open
Abstract
We report the outcome of a pregnant woman with a life-threatening acute respiratory distress syndrome from a novel influenza A (H1N1) virus infection 3 d postpartum successfully managed by veno-arterial extracorporeal membrane oxygenation. The patient was successfully weaned from extracorporeal membrane oxygenation (ECMO) on day 10. Novel H1N1 virus infection was identified by real-time reverse transcription-polymerase chain reaction. Veno-arterial ECMO in this patient carried a number of specific advantages namely maintaining haemodynamic stability obviating the need for inotrope support and improving oxygenation compared to alternative approaches such as veno-venous ECMO and pumpless devices. Femoral arterial and venous cannulae were inserted in a pure percutaneous method allowing rapid establishment of extracorporeal circulation. Given the high mortality of acute respiratory distress syndrome following novel H1N1 virus infection, we advocate the use of ECMO when conventional mechanical ventilation fails.
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