Routine Use of Distal Arterial Perfusion in Pediatric Femoral Venoarterial Extracorporeal Membrane Oxygenation

Lower-extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single-center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty-nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.

[1]  D. Zurakowski,et al.  Extra-Corporeal Membrane Oxygenation Cannulation Site in Patients Above 15 kilograms , 2015 .

[2]  M. Amrani,et al.  Distal limb perfusion: Achilles' heel in peripheral venoarterial extracorporeal membrane oxygenation. , 2014, Artificial organs.

[3]  A. Simon,et al.  Pearls and pitfalls in short-term mechanical circulatory assist: how to avoid and manage complications. , 2014, Artificial organs.

[4]  M. Pozzi,et al.  Femoral artery cannulation through a side graft in extracorporeal membrane oxygenation , 2014, Heart, lung and vessels.

[5]  M. Antonelli,et al.  A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. , 2013, Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine.

[6]  N. Al-Attar,et al.  Arterial vascular complications in peripheral extracorporeal membrane oxygenation support: a review of techniques and outcomes. , 2013, Future cardiology.

[7]  K. Lamb,et al.  Preparation and Technical Considerations for Percutaneous Cannulation for Veno‐Arterial Extracorporeal Membrane Oxygenation , 2013, Journal of cardiac surgery.

[8]  J. Kirklin,et al.  Side-arm grafts for femoral extracorporeal membrane oxygenation cannulation. , 2012, The Annals of thoracic surgery.

[9]  J. Wong,et al.  Cerebral and lower limb near-infrared spectroscopy in adults on extracorporeal membrane oxygenation. , 2012, Artificial organs.

[10]  R. Bartlett,et al.  A simple technique to prevent limb ischemia during veno-arterial ECMO using the femoral artery: the posterior tibial approach , 2012, Perfusion.

[11]  T. Shojima,et al.  A child with influenza A (H1N1)-associated myocarditis rescued by extracorporeal membrane oxygenation , 2010, Journal of Artificial Organs.

[12]  Jason C. Fisher,et al.  Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem. , 2010, Journal of pediatric surgery.

[13]  S. Roddy.  Limb ischemia during femoral cannulation for cardiopulmonary support , 2010 .

[14]  Jason C. Fisher,et al.  Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child. , 2009, Journal of pediatric surgery.

[15]  Christian Kolbitsch,et al.  Near infrared spectroscopy for controlling the quality of distal leg perfusion in remote access cardiopulmonary bypass. , 2008, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[16]  N. Madershahian,et al.  A Simple Technique of Distal Limb Perfusion During Prolonged Femoro‐Femoral Cannulation , 2006, Journal of cardiac surgery.

[17]  N. Kimura,et al.  Perfusion through the dorsalis pedis artery for acute limb ischemia secondary to an occlusive arterial cannula during percutaneous cardiopulmonary support , 2005, Journal of Artificial Organs.

[18]  T Länne,et al.  The diameter of the common femoral artery in healthy human: influence of sex, age, and body size. , 1999, Journal of vascular surgery.

[19]  K. Greason,et al.  Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation. , 1995, The Annals of thoracic surgery.