Arterial Complications Assessed by Duplex Ultrasound After Decannulation of Peripheral Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Vascular complications are common and can be fatal even after successful decannulation in patients with peripherally cannulated veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, we aimed to accurately determine the incidence of arterial complications assessed by Duplex ultrasound following peripheral VA-ECMO decannulation. In addition, we investigated the predictors of severe complications requiring intervention.

METHODS AND RESULTS

We retrospectively reviewed 1,350 adult patients who underwent ECMO between January 2012 and April 2023. Of 839 patients treated with peripherally cannulated VA-ECMO, 596 were successfully weaned off and 212 underwent Duplex ultrasound for final analysis. The primary outcome was arterial complications requiring vascular intervention. Thirty-three (15.6%) patients experienced such complications after decannulation. Acute limb ischemia due to thrombotic occlusion was the most common complication, occurring in 23 (10.8%) patients, followed by stenosis (3.8%), pseudoaneurysm (3.8%), arteriovenous fistula (0.9%), and dissection (0.9%). No significant differences in complication rates were found between the percutaneous and surgical decannulation groups in the propensity score-matched population (12.7% vs. 15.9%, respectively; P=0.799). Multivariable analysis revealed disseminated intravascular coagulation (DIC; odds ratio 2.6; 95% confidence interval 1.17-5.69; P=0.019) as the only predictor of arterial complications after decannulation.

CONCLUSIONS

Arterial complications requiring vascular intervention frequently occur following successful weaning from VA-ECMO regardless of the decannulation strategy. In this setting, DIC appears to be associated with an increased rate of arterial complications.

Innovative Percutaneous 3-Stitch Suture Technique for Site Closure in Venoarterial Extracorporeal Membrane Oxygenation Decannulation Without Direct Artery Repair: A Case Series

No previous studies have reported the use of a percutaneous suture technique performed by bedside intensivists for site closure during decannulation without direct artery repair in venoarterial extracorporeal membrane oxygenation (VA-ECMO) cases. Thus, the objective of this study was to evaluate the safety and effectiveness of this alternative approach. This retrospective study included 26 consecutive patients who underwent percutaneous VA-ECMO decannulation at Maoming People's Hospital. Bedside percutaneous suture technique performed by intensivists facilitated cannula site closure. Primary outcome was successful closure without additional interventions. Secondary outcomes included procedural time, surgical conversion rate, complications (bleeding, vascular/wound complications, neuropathy, lymphocele), procedure-related death. Follow-up ultrasound were conducted within 6 months after discharge. All patients achieved successful site hemostasis with a median procedural time of 28 minutes. Procedure-related complications included minor bleeding (7.7%), acute lower limb ischemia (15.4%), venous thrombus (11.5%), minor arterial stenosis (7.7%), wound infection (4.2%), delayed healing (15.4%), and wound secondary suturing (6.3%). No procedure-related deaths occurred. Follow-up vascular ultrasound revealed two cases (7.7%) of minor arterial stenosis. The perivascular suture technique may offer intensivists a safe and effective alternative method for access site closure without direct artery suture during ECMO decannulation.

Feasibility of a modified hybrid glubran-supported single-proglide technique for access closure during endovascular aneurysm repair

Objective

This study aimed to evaluate the feasibility of a hybrid Glubran-supported single-Proglide technique for large bore femoral access closure during percutaneous access endovascular aneurysm repair (EVAR).

Methods

A retrospective cohort study was performed for all percutaneous EVARs at our center from January 2023 to June 2023. All patients received the hybrid Glubran-supported single-Proglide technique involving a mixture of surgical glue and Lipiodol injection after single suture placement for femoral access closure. Technical success was defined as achieving complete hemostasis without a bailout strategy. Vascular complications and bleeding were defined by Valve Academic Research Consortium-3 (VARC-3) criteria. Vascular access changes and 30-day mortality were recorded.

Results

The technique success rate for the entire study population was 100% (55 femoral access in 37 patients; median age: 72; 78% males). The mean sheath size was 20.4 ± 2.3F. The mean manual compression time was 3.5 ± 1.4 min, the mean hemostasis time was 9.0 ± 2.5 min, and the mean procedural time was 103.9 ± 34.7 min. One patient (1.6%) developed an access site infection and recovered conservatively. No VARC-3 vascular complications and access changes were observed. No 30-day mortality happened.

Conclusions

The hybrid Glubran-supported single-Proglide technique is feasible for large bore access closure during EVAR and may be a viable alternative; however, larger prospective studies are required to confirm its efficacy.

Percutaneous decannulation reduces procedure length and rates of groin wound infection in patients on venoarterial extracorporeal membrane oxygenation

Objective

Open decannulation from femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) carries high risk of morbidity, including groin wound infection. This study evaluated the impact of percutaneous decannulation on rates of groin wound infection in patients decannulated from femoral VA-ECMO.

Methods

Between January 1, 2022, and April 30, 2023, 47 consecutive patients received percutaneous femoral VA-ECMO and survived to decannulation. A percutaneous suture-mediated closure device was used for decannulation in patients with relatively smaller arterial cannulas. Patients with larger arterial cannulas or unsuccessful percutaneous closures underwent surgical cutdown and repair of the femoral artery. The primary outcome was arterial site wound infection following decannulation.

Results

Among the 47 patients who survived to decannulation from VA-ECMO, 21 underwent percutaneous decannulation and 27 underwent surgical cutdown. One patient underwent 2 VA-ECMO runs, one with percutaneous decannulation and one with surgical cutdown. Percutaneous decannulation was attempted in 22 patients, with 21 of 22 (95.5%) success rate. Decannulation procedure length was significantly shorter in the percutaneous group (79 minutes vs 148 minutes, P = .0001). The percutaneous group had significantly reduced rates of groin wound complications (0% vs 40.7%, P = .001) and groin wound infections (0% vs 22.2%, P = .03) when compared with the surgical cutdown group. Three patients (14.3%) in the percutaneous group experienced vascular complications, including pseudoaneurysm at the distal perfusion catheter site and nonocclusive thrombus of the common femoral artery.

Conclusions

Percutaneous decannulation may reduce decannulation procedure length and rate of groin wound infection in patients who survive to decannulation from VA-ECMO.

A Solution for Distal Femoral Occlusion After Venoarterial Extracorporeal Membrane Oxygenation Decannulation: Distal Femoral Access and Thrombectomy

For patients on venoarterial extracorporeal membrane oxygenation support where ready-to-wean criteria are met, complications during the decannulation are quite common. Management of these complications can be challenging as many of the remaining standard arterial access sites are in use or had prior closure by a closure device. In this case report of a 70-year-old patient, explantation of the arterial cannula with the help of a vascular closure device led to thrombotic occlusion of the distal femoral artery. Here, we describe a step-by-step guide outlining our approach on management of this complication. Most relevantly, a distal femoral access via the superficial femoral artery was used, and thrombus aspiration was done with the help of the AngioJet peripheral thrombectomy system.

Ultrasound-guided closure of the femoral artery during venoarterial decannulation using a large-bore closure device

BACKGROUND

Peripheral femoro-femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) is viable for fast hemodynamic assistance during cardiogenic shock. Ultrasound-guided closure with a large-bore device (MANTA®) is a feasible option potentially replacing surgical arteriotomy closure in peripheral VA-ECMO decannulation.

METHODS

This retrospective study included patients weaning from percutaneously inserted femoro-femoral VA-ECMO at the Helsinki University Hospital, Finland in 2012-2020. The primary endpoints were access-site complications, a composite of hematomas/seromas/surgical site infections (SSIs), and the safety endpoint of vascular complications (VCs).

RESULTS

A total of 100 consecutive percutaneously implanted and weaned VA-ECMO patients were stratified into two groups by decannulation strategy: percutaneous ultrasound-guided MANTA device (n = 21, 21.0%) or surgical approach (n = 79, 79.0%). The mean age of the cohort was 51 ± 13 years and females represented 25.0%. The technical success rate of the percutaneous ultrasound-guided MANTA technique was 95.2%. In multivariate analysis, surgical closure was associated with a higher incidence of combined access site hematomas/seromas/SSIs compared to percutaneous ultrasound-guided deployment of MANTA device (44.3% versus 9.5%, odds ratio (OR): 7.162, 95% confidence interval (CI): 1.544-33.222; p = 0.012). Similarly, access-site complications necessitating interventions were more frequent in the surgical closure group compared to US-MANTA (ultrasound-guided MANTA) group (26.6% versus 0.0%, p = 0.005). VCs were infrequent in both groups without any significant intergroup difference (p > 0.99).

CONCLUSIONS

Percutaneous ultrasound-guided MANTA closure of the femoral artery after VA-ECMO decannulation was associated with high technical success rate and low incidence of VCs. Compared to surgical closure, access-site complications were significantly less frequent, along with access-site complications necessitating interventions.

Percutaneous VA-ECMO from Cannulation to Decannulation: Novel Use of a Vascular Closure Device in Pediatrics

VA-ECMO can be lifesaving in cardiogenic shock in children. While surgical vascular repair is the current standard of care for decannulation, it comes with notable risks. We present a series of eight patients who underwent decannulation with a collagen plug-based vascular closure device (MANTA) for the common femoral artery. Seven of the patients were successfully decannulated without access site-related vascular complications. One required conversion to surgical cut-down with arterial repair due to device failure. This series demonstrates the successful use of the MANTA device in percutaneous VA-ECMO decannulation in the pediatric population, while highlighting potential technical challenges for success.

Patient-centered weaning from venoarterial extracorporeal membrane oxygenation: "A practice-oriented narrative review of literature"

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used in cardiogenic shock for rapid stabilization and bridging towards recovery, long-term mechanical circulatory support or transplant. Although technological advances have instigated its widespread use, the complex, long-lasting ECMO care creates a significant strain on hospital staff and resources. Therefore, optimal clinical management including timely decisions on ECMO removal and further therapy are pivotal, yet require a well-structured weaning approach. Although dedicated guidelines are lacking, a variety of weaning protocols have distillated echocardiographic and hemodynamic predictors for successful weaning. Nevertheless, a strikingly high mortality up to 70% after initial successful weaning raises concerns about the validity of current weaning strategies. Here, we plead for a patient-tailored approach including a bailout strategy when weaning fails. This should account not only for left- but also right ventricular function and interdependence, as well as the temporal course of cardiac recovery in function of extracorporeal support. Patients with a high risk of weaning failure should be identified early, enabling timely transportation to an advanced heart failure center. This review summarizes predictors of successful weaning and discusses all relevant elements for a structured weaning approach with a central role for patient-specific clinical considerations and echocardiography.

Efficacy and Safety of Percutaneous Venoarterial Extracorporeal Membrane Oxygenation Decannulation Using Endovascular Balloon Dilation and Perclose ProGlide Closure Device: Results from the Multicenter SKYLINE Study

BACKGROUND

The venoarterial extracorporeal membrane oxygenation (VA-ECMO) cannula can be surgically removed, but postoperative complications and surgical staffing issues can be problematic. We previously reported a method of percutaneously removing the arterial cannula of VA-ECMO by combining intravascular balloon dilation and the Perclose ProGlide (PP) closure device. In this study, we investigated the efficacy and safety of this percutaneous decannulation of the VA-ECMO.

METHODS

This multicenter, retrospective study involved consecutive patients who underwent percutaneous VA-ECMO decannulation at 2 cardiovascular centers from September 2019 to December 2021. We analyzed 37 patients in whom the VA-ECMO cannula was removed by the percutaneous procedure with balloon dilation and the PP. The primary end point was procedural success of hemostasis. The secondary end points were the procedural time, procedure-related complications, and rate of surgical conversion.

RESULTS

The patients' mean age was 65.4 years. The approach site of the endovascular therapy (EVT) procedures were the transradial approach (56.8%), transfemoral approach (27.8%), and transbrachial approach (18.9%). The mean balloon diameter was 7.3 ± 0.68 mm, and the mean balloon inflation time was 14.8 ± 7.3 min. The mean procedure time was 58.5 ± 27.0 min. The procedure success rate was 94.6%, procedure-related complication rate was 10.8%, procedure-related death and postprocedural infection rate was 0.0%, surgical conversion rate was 0.0%, and EVT access site complication rate was 2.7%.

CONCLUSIONS

We concluded that percutaneous VA-ECMO decannulation using a combination of intravascular balloon dilation in EVT and the PP appears to be a safe, minimally invasive, and effective procedure.

Percutaneous decannulation of venoarterial extracorporeal membrane oxygenation using the Manta vascular closure device: A systematic review and meta-analysis

OBJECTIVES

To perform a systematic review and meta-analysis of the techniques and outcomes associated with percutaneous decannulation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) using the Manta vascular closure device.

BACKGROUND

Peripheral VA-ECMO can be used to treat critically ill patients with conditions such as refractory cardiogenic shock. After percutaneous implantation of VA-ECMO, VA-ECMO can also be decannulated completely percutaneously by using a vascular closure device. The Manta vascular closure device is a dedicated device used in the closure of large-bore arteriotomies by sandwiching the arteriotomy with an intra-arterial toggle and an extraluminal collagen plug.

METHODS

We performed a thorough literature search using various electronic databases. We included studies that reported outcomes after peripheral femorofemoral VA-ECMO decannulation with the Manta vascular closure device. We performed a meta-analysis of proportions on outcome measures, including technical success, bleeding complications, vascular complications, wound complications, major amputation, and procedural-related deaths.

RESULTS

We included seven studies with a total of 116 patients. The overall technical success of percutaneous decannulation of VA-ECMO with the Manta vascular closure device was 93.7%. The overall incidence of bleeding, vascular and wound complications was 1.7%, 13.8%, and 3.4%, respectively. No patient required lower limb amputation or died due to VA-ECMO decannulation.

CONCLUSION

Percutaneous decannulation with the Manta vascular closure device is an effective and safe procedure that should be considered in suitable patients on VA-ECMO.

Post-closure with MANTA fluoroscopic DOT technique for emergent percutaneous mechanical circulatory support and 'bail-out' for large bore arterial hemostasis

BACKGROUND

Large bore arterial hemostasis for emergent MCS initiation in cardiogenic shock and during failures of suture mediated vascular closure devices (VCD) necessitates dry/post-closure technique for successful closure. Use of the alternative MANTA fluoroscopic DOT technique, without depth finder, as post closure and as 'bail-out' in this high-risk patient population is described.

METHODS

All patients who underwent emergent percutaneous transfemoral MCS initiation, without use of upfront sutured-mediated pro-glide VCDs, and procedures where proglide-perclose technique (PPT) failed to achieve hemostasis were post-closed with the alternative MANTA fluoroscopic DOT technique (without depth finder) as primary method or as 'bail-out'. Patient related factors, cardiovascular co-morbidities, clinical indication, distribution of 14F versus 18F MANTA, and types of procedures obtained. Primary outcomes of access site related acute flow-limiting limb ischemia or bleeding requiring intervention analyzed.

RESULTS

27 patients met inclusion criteria; mean age 64 years, majority male 19 (70 %), more than half obese (56 %) with mean BMI 31.06 kg/m². 22 (81 %) had emergent MCS initiation and 5 (19 %) PPT hemostasis failures. Types of percutaneous MCS support included; 11 (44 %) Impella CP, 2 (7 %) 15F arterial ECMO, 6 (22 %) 17F arterial ECMO, 4 (15 %) 19F ECMO. All achieved hemostasis utilizing alternative MANTA fluoroscopic DOT technique without vascular complications of bleeding or acute ischemic limb.

CONCLUSION

The alternative MANTA fluoroscopic DOT technique (without depth finder) can be successfully applied as post-closure for emergent MCS support delayed hemostasis and as bail-out for per-close suture mediated VCD failures for large bore arterial hemostasis.

Manual Compression versus Suture-Mediated Closure Device Technique for VA-ECMO Decannulation

Background

The impact of devices for vessel closure on the safety and efficacy of cannula removal in VA-ECMO patients is unknown.

Methods

We retrospectively analyzed 180 consecutive patients weaned from VA-ECMO after cardiac arrest or cardiogenic shock from January 2012 to June 2020. In the first period (historical technique group), from January 2012 to December 2018, primary decannulation strategy was manual compression. In the second period (current technique group), from January 2019 to June 2020, decannulation was performed either by a conventional approach with manual compression or by a suture-mediated closure device technique.

Results

A femoral compression system was necessary in 71% of patients in the historical group compared to 39% in the current technique group (p < 0.01). Vascular surgery was performed in 12% in the historical cohort and 2% in the current technique cohort, which indicated a clear trend, albeit it did not reach significance (p = 0.07).

Conclusion

We illustrated that a suture-mediated closure device technique for VA-ECMO decannulation was feasible, safe, and may have reduced the need of surgical interventions compared to manual compression alone.

Comparing the outcomes of bedside percutaneous VA-ECMO decannulation by ProGlide and Manta in a high-ECMO-volume center in Hong Kong

BACKGROUND

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation with different percutaneous closure devices has been increasing. At our centre, ProGlide devices have been used since November 2018, and Manta devices became an alternative since March 2020. This study aimed to compare the success and complication rates and the clinical outcomes of ProGlide and Manta devices for VA-ECMO decannulation after arteriotomy wound closure.

METHODS

We retrospectively reviewed the results of bedside VA-ECMO decannulation between November 2018 and June 2021. Patients with VA-ECMO who could be bridged to recovery were recruited and divided into the ProGlide or Manta group based on the closure device used. Procedure time, amount of blood loss, amount of blood products transfused, and use of vasoactive medications during the procedure were documented. Clinical examination and Doppler ultrasound were performed to detect any complications.

RESULTS

After the closure technique, ProGlide was used in 44 patients and Manta was used in 13. There was no significant difference in the success rate between the ProGlide and Manta groups (86.4% vs. 100%). Amount of blood loss was greater in the ProGlide group than in the Manta group (290 [100-400] mL vs. 50 [50-100] mL), and more patients in the ProGlide group required an increased dose of inotropes during the procedure (59.1% vs. 15.4%), but the transfusion requirement was similar between the two groups.

CONCLUSIONS

The success rate of haemostasis using arteriotomy wound closure during VA-ECMO decannulation was similar between the two devices.

Percutaneous decannulation of extracorporeal membrane oxygenation using a plug‐based closure device

Background

There is limited experience of using the MANTA plug‐based vascular closure device for percutaneous arterial closure of the femoral artery after venoarterial extracorporeal membrane oxygenation.

Objectives

To study femoral artery complications and need for subsequent vascular interventions after percutaneous decannulation of venoarterial extracorporeal membrane oxygenation (VA ECMO) using the MANTA plug‐based vascular closure device.

Methods

We studied 34 consecutive patients who underwent percutaneous decannulation of VA ECMO using the MANTA device. Primary outcomes were conversion to surgical cutdown of the groin at decannulation (immediate) or later. Secondary outcomes were type of vascular complication necessitating conversion to surgical cutdown of the groin.

Results

Six (17.7%) patients had to undergo immediate (n = 3) or late (n = 3) conversion to surgical cutdown of the groin. Of these, three were owing to occlusion of the common femoral artery resulting in insufficient distal perfusion and three owing to bleeding or pseudoaneurysm. The mechanism of failure was complete intravascular deployment of the MANTA device in three patients, incomplete MANTA sealing of the arteriotomy in one patient, MANTA‐unrelated thrombotic occlusion in one patient, and unknown in one patient. Surgical cut‐down was typically performed with concomitant catheter thrombectomy with or without patch reconstruction of the artery.

Conclusion

Percutaneous decannulation of VA ECMO using the MANTA VCD was feasible but a substantial number of patients needed to be converted to unplanned surgical repair, owing to either closure site‐located stenosis/occlusion or bleeding. If suboptimal MANTA positioning is suspected, a low threshold for conversion to surgical cutdown of the groin is recommended.

Percutaneous angio-guided versus surgical veno-arterial ECLS implantation in patients with cardiogenic shock or cardiac arrest

BACKGROUND

Veno-arterial Extracorporeal Life Support (V-A ECLS) has gained increasing place into the management of patients with refractory cardiogenic shock or cardiac arrest. Both surgical and percutaneous approach can be used for cannulation, but percutaneous approach has been associated with fewer complications. Angio-guided percutaneous cannulation and decannulation may further decrease the rate of complication. We aimed to compare outcome and complication rates in patients supported with V-A ECLS through percutaneous angio-guided versus surgical approach.

METHODS

We included all patients with emergent peripheral femoro-femoral V-A ECLS implantation for refractory cardiogenic shock or cardiac arrest in our center from March 2018 to March 2021. Survival and major complications (major bleeding, limb ischemia and groin infection) rates were compared between the percutaneous angio-guided and the surgical groups.

RESULTS

One hundred twenty patients received V-A ECLS, 59 through surgical approach and 61 through angio-guided percutaneous approach. Patients' baseline characteristics and severity scores were equally balanced between the 2 groups. Thirty-day mortality was not significantly different between the 2 approaches. However, angio-guided percutaneous cannulation was associated with fewer major vascular complications (42% vs. 11%, p > 0.0001) and a higher rate of V-A ECLS decannulation. In multivariate analysis, percutaneous angio-guided implantation of V-A ECLS was independently associated with a lower probability of major complications.

CONCLUSION

Compared to surgical approach, angio-guided percutaneous V-A ECLS implantation is associated with fewer major vascular complications. Larger studies are needed to confirm those results and address their impact on mortality.

Efficacy of Vascular Closure Devices in Closing Large-Bore Sheath Arterial Sites after Treatment with Extracorporeal Life Support System

BACKGROUND

 We retrospectively evaluated vascular complications and wound infections after surgical or percutaneous transfemoral removal of temporary extracorporeal life support systems (ECLSs).

METHODS

 A total of 83 patients were weaned from ECLS between August 2015 and September 2020. We analyzed for a composite endpoint of vascular complications and wound infections requiring negative-pressure wound therapy. Patients were divided into two groups: percutaneous group using the MANTA vascular occlusion system (VCD; Teleflex, Morrisville, North Carolina, United States) (n = 23) and surgical group (n = 60).

RESULTS

 The median age in the entire cohort was 67 years. Vascular complications were seen in 20% (n = 12) in the surgical group and in 13% (n = 3) in the percutaneous group (p = 0.72). A total of 32% (n = 19) in the surgical group and 9% (n = 2) in the percutaneous group (p = 0.031) had wound infections. A composite endpoint of vascular complications and wound infections showed significantly more complications in the surgical group (52%, n = 31) as compared with the percutaneous group (22%, n = 5) (p = 0.020). The median duration in the intensive care unit was 13 days for the surgical group and 12 days for the percutaneous group without any significant difference in both groups (p = 0.93).

CONCLUSIONS

 Using the MANTA VCD for percutaneous removal of ECLS cannulas after weaning from ECLS is safe and reproducible. A composite endpoint of vascular complications and wound infections was significantly lower in the percutaneous removal group as compared with the surgical group.

Impact of pulse pressure on clinical outcome in extracorporeal cardiopulmonary resuscitation (eCPR) patients

BACKGROUND

Hemodynamic response to successful extracorporeal cardiopulmonary resuscitation (eCPR) is not uniform. Pulse pressure (PP) as a correlate for myocardial damage or recovery from it, might be a valuable tool to estimate the outcome of these patients.

METHODS

We report retrospective data of a single-centre registry of eCPR patients, treated at the Interdisciplinary Medical Intensive Care Unit at the Medical Centre, University of Freiburg, Germany, between 01/2017 and 01/2020. The association between PP of the first 10 days after eCPR and hospital survival was investigated. Moreover, patients were divided into three groups according to their PP [low (0-9 mmHg), mid (10-29 mmHg) and high (≥ 30 mmHg)] at each time point.

RESULTS

One hundred forty-three patients (age 63 years, 74.1% male, 40% OHCA, average low flow time 49 min) were analysed. Overall hospital survival rate was 28%. A low PP both early after eCPR (after 1, 3, 6 and 12 h) and after day 1 to day 8 was associated with reduced hospital survival. At each time point (1 h to day 5) the classification of patients into a low, mid and high PP group was able to categorize the patients for a low (5-20%), moderate (20-40%) and high (50-70%) survival rate. A multivariable analysis showed that the mean PP of the first 24 h was an independent predictor for survival (p = 0.008).

CONCLUSION

In this analysis, PP occurred to be a valuable parameter to estimate survival and maybe support clinical decision making in the further course of patients after eCPR.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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