Background
Methods
Author, year | Type of study | Patient population | Study endpoint | Main comorbidity | Mean ECMO duration | H survival | Arterial cannula size | Cannulation technique | Decannulation technique | Limb ischemia | DPC timing | DPC size | Ischemia therapy/limb outcome |
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Sabashnikov, 2018 [24] | R | 28 pts. (15 under CPR): 3 (11%) ARDS 1 (3%) DCM 17 (61%) ICM 5 (18%) PAE 1 (3%) MIO 1 (3%) PCS | Primary: Early and mid-term overall cumulative survival (2 years follow-up) Secondary: -Incidences of ECMO-related complications, -Impact of CPR on outcome and changes in hemodynamics -Tissue perfusion factors 24 h after cannulation | NA | 96 ± 100 h | 11 (40%) | 21–23 Fr | PC 27 (90%) SCD 1 (10%) | NA | 3 (10%) | Pre-emptive 19 (68%) | 6.5 (6.5–8) | Surgical exploration of the femoral artery and embolectomy using a Fogarty catheter. |
Park, 2018 [25] | R | 255 pts. with HF and/or ARF | Identify risk factors for lower limb ischemia | CAD 83 (32.5%) PVD 5 (2%) | 89.8 h | NA (30 days survival 69.8%) | 16.5 ± 1.8 | PC | NA | 24 (9.4%) | Pre-emptive 23 (9%) Rescue 14 (5.5%) | 5–7 Fr | 2 surgical catheter removal (functional deficit). 14 rescue DPC (Of those, 2 needed surgical intervention and survived with functional deficit.) |
Yen, 2018 [14] | R | 139 pts.: LI group n = 46 No LI group n = 93 | Identify pre-cannulation variables that are associated with limb ischemia and selection criteria for using DPC for prevention of limb ischemia | No LI group: DM 16 (17%) HT 28 (30%) Uremia 10 (11%) PVD 8 (9%) LI group: DM 10 (22%) HT 17 (37%) Uremia 8 (17%) PVD 11 (24%) | NA | No LI group: 69 (74%) LI group: 25 (54%) | 16.5 ± 0.8 | PC | NA | 46 (33%) | Rescue | 6 Fr | NA |
Burrell, 2018 [26] | R | 144 pts | Complications and outcomes of patients who were commenced on ECMO at a referring hospital compared with patients who had ECMO in a referral center for ECMO. | S 35 (26%) CAD 35 (26%) DM 16 (12%) HF 69 (53%) CT 18 (13%) | 7 (4–11) days | 105 (72.9%) | 17–19 Fr | PC | NA | 1 (0.7%) | Pre-emptive | 9 Fr | Resolved after DPC insertion at the referral center |
Voicu, 2018 [27] | R | 46 pts. with refractory CA | Analyze the feasibility and the time interval required for percutaneous cannulation versus anatomic landmark cannulation for va ECMO. | S 21 (46%) DM 5 (11%) HT 17 (37%) HL 15 (33%) | NA | 4 (9%) | 15–17-19 Fr | PC | NA | 0 | Pre-emptive | 4 Fr | NA |
Salna, 2018 [28] | R | 192 pts. with CS: 35% AMI 23% PCS 18% ADHF 15% PGD 8.9% other | Incidence of in-hospital lymphocele formation in VA-ECMO patients and identify predictors for its development | DM 65 (33.9%) CKD 52 (27.1% PVD 19 (9.4%) | 4 (2–6) days | 120 (62.5%) | 15–17 Fr | SCD 88 (45.8%) | Surgical | 16 (8.3%) | Preventive based on Doppler signal at cannulation | 6–10 Fr | NA |
Lamb, 2017 [29] | R | 91 patients: CS 73 (80%); ARF 14 (15%) PE 3 (4%) VAD failure 1 (1%) | Evaluation of an ischemia prevention protocol | HT 53 (58%) DM 26 (29%) HL 34 (37%) OB 30 (33%) CLD 15 (17%) PVD 6 (7%) CKD 27 (30%) | 9 days | 38 (42%) | 16-24 Fr on pressure-flow curve and pts. size | PC | Surgical | 12 (13%) all in patients without preventive DPC | Preventive 55 (60%) Rescue 7 (8%) | 5 Fr | DPC 2 (2.2%) DPC+ Fasciotomy 5 (5.5%) Fasciotomy 4 (4.3%) |
Pasrija, 2017 [30] | R | 20 pts. with PE | Primary outcome: In-hospital and 90-day survival. Secondary outcomes: -Acute kidney injury that required renal replacement therapy -New hemodialysis at discharge -Sepsis, -Tracheostomy, -RV dysfunction at discharge -ECMO-related complications (bleeding that required blood product, stroke after cannulation and vascular complications) | NA | 5.1 (3.7–6.7) days | 19 (95%) | 17–19 Fr | PC | NA | 0 | Pre-emptive | 6 Fr | 1 vascular injury due to retrograde type B dissection after ECMO cannulation. Required central cannulation. |
Vallabhajosyula, 2016 [31] | R | 105 pts. on femoral VA-ECMO: G1 = no DPC G2 = PC DPC G3 = Surgical DPC | Assess if the type of limb perfusion strategy influenced the rate and severity of ipsilateral limb ischemia in peripheral ECLS patients | DM 24 (33%) HT 39 (37%) S 22 (21%) | G1 87.7 ± 119 h G2 88.5 ± 121 h G3 89.2 ± 120 h | G1 21 (60%) G2 14 (61%) G3 32 (68%) | 16–20 Fr | NA | NA | G1 7 (20%) G2 6 (26%) G3 1 (2.1%) | Pre-emptive 70 (67%) | 7 Fr | 4 tromboembolectomy + artery repair 4 fasciotomy 3 cannulation revision 1 amputation |
Yeo, 2016 [32] | R | 151 pts.: G1 = pre-emptive DPC (44pts) G2 = rescue DPC (107 pts) | Evaluate the efficacy of pre-emptive DPC during ECMO support in term of limb ischemia prevention | DM 25 (16.4%) HT 39 (25.7%) CKD 6 (3.9%) S 27 (17.8%) PVD 11 (7.2%) CVD 5 (3.4%) | G1 4.9 ± 4.9 days G2 6.0 ± 5.4 days | (Overall mortality G1 66 (61.7%) G2 17 (38.6%)) | G1 17.2 ± 2.1 Fr G2 17.9 ± 1.8 Fr | PC | NA | 10 (6.7%) all in G2 | Pre-emptive G1 Rescue G2 | 5–8 Fr | 2 DPC 2 fasciotomy 1 amputation 5 died before therapeutic intervention |
Avalli, 2016 [33] | R | 100 pts.: G1 with vascular complications 35 (35%) G2 without vascular complications 65 (65%) | Primary endpoint was early vascular complication rate. Secondary endpoint was 1-month and 6-month survival | PVD 8 (8%) CAS 4 (4%) HT 59 (59%) DM 19 (19%) S 25 (25%) HL 20 (20% OB 13 (13%) | G1 5 (3–6) days G2 4.5 (2–9) days | G1 15 (43%) G2 13 (20%) | 15–17 Fr | PC | Manual compression 30′ + SafeGuard | 34 (34%) | Rescue | 7–9 Fr | 30 DPC 6 fasciotomy 1 amputation |
Tanaka, 2016 [19] | R | 84 pts. on pVA-ECMO. 17/84 with vascular complication (G1) 67/84 without vascular complication (G2) | Impact of vascular complications on survival in patients receiving VA ECMO by means of femoral percutaneous cannulation. | S 28 CAD 34 PVD 3 DM24 COPD 10 | G1 14.6 ± 6.7 G2 10.6 ± 7.5 | G1 3 (18%) G2 32 (48%) | G1 19.8 ± 2.3 G2: 19.7 ± 1.7 | PC | Surgical | 10 (12%) | Pre-emptive except 7 (41%) G1 10 (15%) G2 | NA | Prophylactic fasciotomy |
Ma, 2016 [34] | R | 70 pts. PCS 44 (63%) ECPR 21 (30%) ARF 5 (7%) | To identify predictive factors for vascular complications, and provide insight into how to reduce these complications | NA | NA | NA | 15–24 Fr | 44 (63%) SCT 25 (36%) PC 1 not recorded | Surgical | 14 (20%) | 33 Pre-emptive 6 Rescue | 6–8.5 Fr | 6 DPC rescue 1 embolectomy 1 fasciotomy 1 embolectomy+ femoral artery repair 1 amputation |
Esper, 2015 [35] | R | 18 pts. with ACS complicated by CS | Single-center experience | DB 5 (27.8%) HT 9 (50%) HL 2 (11.1%) S 3 (16.7%) PVD 3 (16.7%) | 3.2 ± 2.5 days | 67% | 15–17 FR | PC | NA | 4 (22%) | Rescue | NA | DPC |
Takayama,2015 [36] | R | 101 Group L: (n 51) Group S (n 50) | To compare the clinical outcomes of 2 strategies: conventional approach (using a 15F–24F cannula- Group L) or smaller cannula of15 Fr (Group S) | Group L CAD 22 (43) Ht 26 (51) HL 15 (29) DM 17 (33) COPD 17 (14) Group S CAD 31 (62) HT 33 (66) HL 23 (46) DM 16 (32) COPD 5 (10) | Group L 3.4 (1.0–6.1) days Group S 3.1 (1.9–5.1) days | Group L 31 (61%) Group S 27 (54%) | Group L 17 to 24Fr Group S 15 Fr | Group L PC 22 (43) SCD 29 (57) Group S PC 44 (88) SCD 6 (12) | NA | Group L 2 (4) Group S 2 (4) | Group L 19% Group S 18% Inserted if distal doppler signal is lost | NA | NA |
Truby, 2015 [37] | R | 179 pts. with CS | Trends in device usage, and analysis of clinical outcomes | CAD 82 (45.8%) HL 72 (40.2%) HT 103 (57.5%) CLD 16 (8.8%) DB 52 (29.1%) | 3.58 days | 69 (38.6%) | 15–23 Fr | NA | NA | 25 (13.9%) | 9 Rescue | NA | 2 Fasciotomy |
Saeed, 2014 [38] | R | 37 pts.: 25 p VA ECMO | Compare outcome of cECMO versus pECMO patients in the immediate postoperative period. | DM 3 (12%) HT 13 (52%) HL 8 (32%) CAS 3 (12%) CKD 9 (36%) Re-do surgery 5 (20%) | 5.8 ± 4.3 days | (30-day mortality 60%) | 18–22 Fr | NA | NA | 4 (16%) | Pre-emptive | NA | All required surgical intervention |
Aziz, 2014 [39] | R | 101 pts | Incidence of peripheral vascular complication | HT 33 (32.7%) DM 22 (21.8%) HL 22 (21.8%) S 20 (19.8%) | 7.3 days | 59 (58.4%) | 15–17 Fr | PC | S | 8 (8%) | 77 (77%) Pre-emptive | NA | 8 arterial cannula removal 4 femoral endoarterectomy with patch angioplasty 1 amputation |
Papadopoulos, 2014 [40] | R | Total: 360 PCS. 120 (37%) femoral pVA-ECMO | Identification of risk factors for adverse outcome (failed ECLS weaning or in-hospital mortality) | COPD 32 (9%) HT 227 (63%) PH 31 (17%) DM 151 (42%) CVD 22 (6%) PVD 65 (18%) S 122 (34%) CKD 40 (11%) | 7 ± 1 days | 108 (30%) | NA | Seldinger or 8-mm Dacron Graft | NA | 20 (17% of femoral pVA-ECMO) | NA | NA | Fasciotomy 18 (5% of total pts) NA data on femoral pVA-ECMO pts. |
Stub, 2014 [41] | SC-POT | 26 pts. ECPR (24 cannulated) | Primary outcome: Survival with good neurologic recovery Secondary outcomes: Rates of ROSC, successful weaning from ECMO support and ICU and hospital length of stay. | HT 11 (42%) HL 11 (42%) DM 2 (8%) HF 5 (19%) CAD 4 (15%) | 2 (1–5) days | 14 (54%) | 15 Fr | PC | S | 10 (42%) | As soon as possible after ICU admission | 8.5 Fr | 9 femoral artery repair and surgical placement of DPC 1 fasciotomy |
Mohite, 2014 [42] | R | 45 pts.: 14 ADHF 8 PCS 6 CS 15 Post CT 2 Bridge to LungT | Compare pts. outcomes focusing on the distal limb perfusion methods (perfusion cannula VS introducer sheat) | NA | Perfusioncannula group: 11.9 ± 9.1 days Introducer sheat group 7.7 ± 4.3 | 19 (42.2%) | 19–21 Fr | 20 (44.5%) PC 14 (31%) SCT 11 (24%) Hybrid | NA | 9 (20%) | Pre-emptive | Perfusion cannula 10–12 Fr Introducer sheat 6–8 Fr | 5 (11.2%) conservative 4 (8.8%) surgery 1 amputation |
Spurlock, 2012 [43] | R | On 154 patients (data on 36 patients in PTA-DPC) | Posterior tibial artery for DPC placement | NA | 5.8 days | 63 (41%) | 15–24 Fr on surgeon decision | PC | Direct pressure 30 mins | Available only for PTA-DPC group) 3 (8.3%) | DPC in 68 (44%) PTA-DPC in 36 (24%): 20 (58%) within 6 h of ECMO; 16 (42%) after 6 h of ECMO | 6–8 Fr | (Available only for PTA-DPC group) 2 amputation 1 neuropathy |
Wong, 2012 [44] | R | 20 pts.: 17 (85%) on VA-ECMO | Report single-center experience on cerebral and lower limb NIRS | NA | 7 (2–26) days | NA | NA | PC | NA | 6 (35%) diagnosed with drop in unilateral lower limb NIRS tracings | Pre-emptive | NA | 4 two-compartment prophylactic fasciotomy |
Wernly, 2011 [45] | R | 51 pts. with Hantavirus cardiopulmonary syndrome | Evaluate the outcome of ECMO support in Hantavirus cardiopulmonary syndrome (HCPS) patients | NA | 121.7 h | 34 (66.6%) | 15–21 Fr | PC 18 (35.3%) SCD 33 (64.7%) | SCD | 4 (8%) | Pre-emptive | 8–10 Fr | 2 thrombectomy, embolectomy, and insertion of an additional cannula in the superficial femoral artery. 2 Amputations |
Ganslmeier, 2011 [46] | NA | 158 pts | Reviews cannulation strategies and associated vascular complications | NA | 3.6 ± 5.2 days | 32 (20%) | 13–15–17-19 Fr | PC SCT if femoral vessels were small during sonography | Safeguard system | 13 (8.2%) | NA | NA | 50% Surgical revision and vascular reconstruction 100% prophylactic fasciotomy |
Bisdas,2011 [15] | R | 143 pts. with ECMO VA | To evaluate such complications to outline basic technical principles for their prevention. | HT 77 (44%) CKD 53 (30%) CAD 47 (27%) COPD 25 (14%) DM 29 (17%) PAD 15 (9%) | 6 days (range, 1 to 11 days). | 26% | 15F or 17F | Percutaneous cannulation in 136 (95%) and by open vessel exposure in 7 (5%). | Manual compression, and femoral compression system | 8 pts | Pre-emptive | 6F | 2 amputation |
Foley, 2010 [47] | R | 43 pts. on femoral pVAECMO | Examine the outcomes of patients placed on ECMO, including the rate of limb ischemia | NA | NA | NA | Li group 16.9 ± 1.1 No li group 18.0 ± 1.7 Pre-emptive DPC group 17.7 ± 1.8 | PC | Surgical | 7 (21%) | 10 pre-emptive 3 Rescue | NA | 4 Decannulation and fasciotomy 3 rescue DPC 1 amputation |
Arlt, 2009 [48] | R | 13 pts.: 10 (77%) CS 3 (27%) Septic shock | Report 9 years emergency ECMO application | NA | 3.5 ± 2.9 days | 8 (62%) | 15–17 Fr | PC | NA | 6 (46%) | Not used | NA | Resolved limb ischemia after cannula switch from the femoral artery to the right subclavian artery. |
Narrative review
Incidence of limb ischemia in pV-A ECMO
Pathophysiology and risk factors
Diagnosis
Every hour | Every shift | Altered perfusion | |
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Bedside nurse | Bilateral clinical evaluation | Doppler pulse check | Doppler pulse check |
Temperature | |||
Appearance | |||
Refilling Time | |||
ECMO specialist | Bilateral clinical evaluation | Bilateral clinical evaluation | |
ECMO flow check | ECMO flow Check | ||
Vasopressor balance | Vasopressor balance | ||
DPC flow check | DPC flow check | ||
NIRS | NIRS | NIRS | NIRS |
Radiologist | ECHO Doppler | ||
Angiography |