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Published on: January 17, 2025
Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an
Jeffrey W Gander1, Jason C Fisher, Ari R Reichstein
1Department of Surgery, Division of Pediatric Surgery, Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA. jwg2107@columbia.edu
Insights
Limb ischemia is a significant complication in pediatric patients undergoing venoarterial extracorporeal membrane oxygenation (VA ECMO) via common femoral artery (CFA) cannulation. No pre-cannulation variables predicted ischemia, suggesting a need for proactive strategies like routine distal perfusion catheter placement.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular surgery
- Extracorporeal life support
Background:
- The use of extracorporeal membrane oxygenation (ECMO) is increasing in pediatric patients.
- Common femoral artery (CFA) cannulation is preferred over carotid artery ligation to avoid neurologic complications.
- CFA cannulation carries a risk of lower limb ischemia due to potential cannula-induced flow obstruction.
Purpose of the Study:
- To evaluate the incidence of significant limb ischemia in pediatric patients undergoing VA ECMO via CFA cannulation.
- To identify any pre-cannulation clinical variables that correlate with the development of limb ischemia.
Main Methods:
- A retrospective review of pediatric patients who underwent VA ECMO with CFA cannulation between 2000 and 2010.
- Patients were categorized into 'ischemia' (requiring intervention) and 'no-ischemia' groups.
- Statistical analysis included Mann-Whitney U tests for continuous variables and Fisher's Exact test for categorical variables.
Main Results:
- Of 21 patients, 11 (52%) experienced significant limb ischemia requiring intervention.
- No pre-cannulation clinical variables were found to predict the development of limb ischemia.
- Distal perfusion catheters (DPCs) were used in 81% of the ischemia group, with associated complications including compartment syndrome and toe amputation.
Conclusions:
- Limb ischemia is a frequent complication following CFA cannulation for VA ECMO in children.
- Predictive pre-cannulation variables were not identified in this study.
- Routine DPC placement may be considered, but new strategies are needed to prevent limb ischemia and loss.
Purpose:
Extracorporeal Life Support Organization Registry data confirm that the number of pediatric patients being supported by extracorporeal membrane oxygenation (ECMO) is increasing. To minimize the potential neurologic effects of carotid artery ligation, the common femoral artery (CFA) is frequently being used for arterial cannulation. The cannula has the potential for obstructing flow to the lower limb, thus increasing ischemia and possible limb loss. We present a single institution's experience with CFA cannulation for venoarterial (VA) ECMO and ask whether any precannulation variables correlate with the development of significant limb ischemia.
Methods:
We reviewed all pediatric patients who were supported by VA ECMO via CFA cannulation from January 2000 to February 2010. Limb ischemia was the primary variable. The ischemia group was defined as the patients requiring an intervention because of the development of lower extremity ischemia. The patients in the no-ischemia group did not develop significant ischemia. Continuous variables were reported as medians with interquartile ranges and compared using Mann-Whitney U tests. Differences in categorical variables were assessed using χ² testing (Fisher's Exact). Statistical significance was assumed at P < .05.
Results:
Twenty-one patients (age, 2-22 years) were cannulated via the CFA for VA ECMO. Significant ischemia requiring intervention (ischemia group) occurred in 11 (52%) of 21. In comparing the 2 groups (ischemia vs no ischemia), no clinical variables predicted the development of ischemia (Table 1). In the ischemia group, 9 (81%) of 11 had a distal perfusion catheter (DPC) placed. Complications of DPC placement included one case of compartment syndrome requiring a fasciotomy and one patient requiring interval toe amputation. Of the 2 patients in the ischemia group who did not have a DPC placed, 1 required a vascular reconstruction of an injured superficial femoral artery and 1 underwent a below-the-knee amputation. Mortality was lower in the ischemia group (27% vs 60%).
Conclusions:
Limb ischemia remains a significant problem, as more than half of our patients developed it. The true incidence may not be known as a 60% mortality in the no-ischemia group could mask subsequent ischemia. Although children are at risk for developing limb ischemia/loss, no variable was predictive of the development of significant limb ischemia in our series. Because of the inability to predict who will develop limb ischemia, early routine placement of a DPC at the time of cannulation may be warranted. However, DPCs do not completely resolve issues around tissue loss and morbidity. Prevention of limb ischemia/loss because of CFA cannulation for VA ECMO continues to be a problem that could benefit from new strategies.
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