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Side-Arm Grafts for Femoral Extracorporeal Membrane Oxygenation Cannulation
Side-Arm Grafts for Femoral Extracorporeal Membrane Oxygenation Cannulation Kimberly W. Jackson, MD, Joseph Timpa, CCP, FFP, R. Britt McIlwain, MPS, CCP, Carlisle O’Meara, RRT, CCP, James K. Kirklin, MD, Santiago Borasino, MD, MPH, and Jeffrey A. Alten, MD Division of Pediatric Critical Care Medicine, Division of Cardiovascular Services, and Division of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
Lower extremity ischemia is an important source of morbidity with femoral venoarterial extracorporeal membrane oxygenation support. We describe our experience with the use of a side-arm graft sewn to the femoral artery that facilitates adequate extracorporeal membrane oxygenation flow while preventing lower extremity ischemia. (Ann Thorac Surg 2012;94:e111–2) © 2012 by The Society of Thoracic Surgeons
T
he femoral vessels are the preferred site for venoarterial extracorporeal membrane oxygenation (VAECMO) in adults and older children because of the decreased incidence of neurologic complications, ease of cannulation, and decreased bleeding when percutaneous techniques are used. Lower extremity (LE) ischemia is a complication of femoral VA-ECMO, with the potential for severe sequelae, including tissue loss and amputation [1, 2]. Alternative techniques, such as distal perfusion catheters (DPC), have been developed to improve the flow distal to the arterial cannula [3– 6]; yet, ischemia continues to complicate femoral VA-ECMO [1]. We describe 3 consecutive patients who underwent cannulation for VA-ECMO by a side-arm graft sewn to the femoral artery (FA) that does not compromise LE perfusion. After exposure, an exclusion clamp is placed on the FA, and a longitudinal incision is made. An anastomosis of an 8-mm Gelweave Dacron graft (Vascutek, Scotland, UK) is made end-to-side to the FA with two layers of continuous 5– 0 Prolene sutures. The graft is tunneled inferiorly under the skin, remaining entirely in a subcutaneous position. The graft is attached to a ¼-inch ⫻ 3/8-inch tubing connector (Intersept, Medtronic Inc, Minneapolis, MN) outside the skin and subsequently connected to the ECMO arterial tubing (Fig 1). During decannulation, the graft is clamped close to the FA, divided, and oversewn with two layers of continuous 5– 0 Prolene sutures.
Case Reports Patient 1 A 15-year-old boy presented with cardiovascular collapse secondary to viral myocarditis. He was emergently given VA-ECMO by percutaneous cannulation with 17F right FA and 21F right femoral venous (FV) cannulas. After stabilization, he experienced decreased perfusion and Accepted for publication May 4, 2012. Address correspondence to Dr Alten, University of Alabama at Birmingham, 1600 7th Ave S, ACC 504, Birmingham, AL 35233; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Anastomosis of an 8-mm side-arm graft in an end-to-side fashion to the femoral artery, tunneled under the skin, and attached to a tubing connector, which is then connected to the arterial extracorporeal membrane oxygenation (ECMO) line.
absence of pulse in his right LE. Because of persistent ischemia, he underwent a side-arm graft anastomosis to the contralateral FA, as described earlier. The right FA cannula was removed, and distal perfusion normalized. The FA graft provided excellent flow to his upper body, as demonstrated by normal radial artery and cerebral near-infrared spectroscopy (cNIRS) saturations. He had no further ischemic or bleeding complications as result of either cannulation site, and weaning from ECMO on day 8 was successful.
Patient 2 A 22-year-old man with congenital aortic stenosis was admitted with worsening stenosis and decompensated heart failure. His condition became unstable, with frequent episodes of syncope and coronary ischemia, requiring VA-ECMO. Percutaneous cannulation was performed with 19F right FA and 21F right FV cannulas with the patient under moderate sedation. After stabilization, he underwent general anesthesia for revision of the arterial cannulation to a side-arm graft; the initial arterial cannula was removed. The next day a large hematoma was noted at the cannulation site; bedside exploration revealed diffuse oozing at the graft anastomosis suture line. Bleeding was controlled with pledgeted suture and a bovine pericardial patch to tamponade further oozing. He had no further bleeding complications and maintained excellent distal lower extremity perfusion. His radial artery saturations and cNIRS remained normal during ECMO support. On ECMO day 3, he underwent balloon dilatation of his aortic valve with improvement of his ventricular function, enabling successful weaning from ECMO the next day.
Patient 3 A 43-year-old man with tetralogy of Fallot presented for tricuspid valve replacement. He underwent cannulation 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.064
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CASE REPORT JACKSON ET AL SIDE-ARM GRAFTS FOR FEMORAL EXTRACORPOREAL MEMBRANE OXYGENATION CANNULATION
for cardiopulmonary bypass (CPB) with a left FA cannula. A long intraoperative course was complicated by severe bleeding. After weaning from CPB, he experienced low cardiac output and rapidly progressive lactic acidosis, requiring VA-ECMO support by a side-arm graft attached to the left FA and a 25F FV cannula. Severe postoperative bleeding precluded the initial use of heparin; the cannulation site was packed with sponges, and the skin temporarily closed with a bovine pericardial patch. He experienced no further bleeding complications and maintained normal LE perfusion. Weaning from ECMO was successful day three.
Comment The femoral vessels are frequently cannulated for VAECMO because they offer relatively easy access to the central circulation and are associated with decreased bleeding and neurologic complications. Because the arterial cannula may approach the diameter of the FA, distal leg perfusion can become compromised. The incidence of LE ischemia ranges from 10% to 50% in patients with FA cannulation [1, 2]. The procedure in this report was adapted from the axillary artery CPB cannulation technique used by our cardiovascular surgeons. The success of this technique in rescuing our first patient from LE ischemia led us to explore it as our primary method of FA ECMO cannulation. We believe that ischemia related to cannula obstruction could be eliminated with this side-arm graft technique. All 3 patients demonstrated excellent LE perfusion (warm and pink), with easily palpable pulses once contractility returned. Historically, our patients whose FAs were directly cannulated had a temperature difference between the feet and rarely had palpable LE pulses. Other techniques are reported to decrease the risk of distal leg ischemia seen in femoral VA-ECMO; most involve variations of DPCs that can be percutaneously or surgically placed distal to the ECMO cannulation site [3– 6]. Investigators have still reported ischemia and tissue damage with their use, side effects of their placement, or both [1]. Our side-arm graft technique avoids intraluminal cannulas entirely, which should nearly eliminate the occurrence of LE ischemia in addition to allowing antegrade and retrograde blood flow. All 3 patients had normal retrograde (upper body) oxygen delivery as measured by cNIRS monitoring and measurements of radial arterial and superior vena cava venous saturation. The anastomosis of prosthetic vascular grafts to the FA has previously been described for CPB [7] and ECMO support [8]. Although they did not describe it in detail, Doll and colleagues [8] mentioned performing anastomosis of a 6-mm Hemashield prosthesis to the FA in a review of their vast ECMO experience. They observed decreased ischemia after the change from percutaneous cannulation, but it is not clear how many patients under-
Ann Thorac Surg 2012;94:e111–2
went cannulation in this manner and whether increased bleeding or other complications resulted. One advantage of femoral cannulation is that the vessels are easily cannulated percutaneously, offering the potential for emergent access. Our technique requires cutdown exposure and arteriotomy of the FA, increasing cannulation time and bleeding risks in comparison with the percutaneous technique. The second patient highlighted this limitation, given that he had significant bleeding at the anastomosis site, requiring reexploration. The potential for increased risk of bleeding and infection (foreign material) makes it necessary to delineate patient populations that may benefit most from this cannulation technique. Patients with smaller vessels likely to be occluded by arterial cannulas [4] (children, thin adults, peripheral artery disease [2]), patients in whom ischemia develops after percutaneous cannulation, or patients who undergo cannulation in the operating room with vessels already exposed for CPB (similar to our third patient) all may be attractive candidates for this approach. In conclusion, our variation of a side-arm graft to establish FA access is effective in reversing or preventing distal LE ischemia, or both, associated with femoral VA-ECMO. Prospective studies are necessary to determine whether this technique has a sufficiently favorable side effect profile compared with percutaneous cannulation to warrant its prophylactic use in all patients.
References 1. Gander JW, Fisher JC, Reichstein AR, et al. Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem. J Pediatr Surg 2010;45:2136 – 40. 2. Bisdas T, Beutel G, Warnecke G, et al. Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. Ann Thorac Surg 2011;92:626–31. 3. Russo CF, Cannata A, Vitali E, Lanfranconi M. Prevention of limb ischemia and edema during peripheral venoarterial extracorporeal membrane oxygenation in adults. J Card Surg 2009;24:185–7. 4. Haley MJ, Fisher JC, Ruiz-Elizalde AR, Stolar CJ, Morrissehy NJ, Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child. J Pediatr Surg 2009;44:437– 40. 5. Greason KL, Hemp JR, Maxwell JM, Fetter JE, Moreno-Cabral RJ. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation. Ann Thorac Surg 1995;60:209 –10. 6. Kasirajan V, Simmons I, King J, Shumaker MD, DeAnda A, Higgins RS. Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation. Perfusion 2002;17:427– 8. 7. Vander Salm TJ. Prevention of lower extremity ischemia during cardiopulmonary bypass via femoral cannulation. Ann Thorac Surg 1997;63:251–2. 8. Doll N, Kiaii B, Borger M, et al. Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock. Ann Thorac Surg 2004;77:151–7; discussion 157.
Lower extremity ischemia is an important source of morbidity with femoral venoarterial extracorporeal membrane oxygenation support. We describe our experience with the use of a side-arm graft sewn to the femoral artery that facilitates adequate extracorporeal membrane oxygenation flow while preventing lower extremity ischemia. (Ann Thorac Surg 2012;94:e111–2) © 2012 by The Society of Thoracic Surgeons
T
he femoral vessels are the preferred site for venoarterial extracorporeal membrane oxygenation (VAECMO) in adults and older children because of the decreased incidence of neurologic complications, ease of cannulation, and decreased bleeding when percutaneous techniques are used. Lower extremity (LE) ischemia is a complication of femoral VA-ECMO, with the potential for severe sequelae, including tissue loss and amputation [1, 2]. Alternative techniques, such as distal perfusion catheters (DPC), have been developed to improve the flow distal to the arterial cannula [3– 6]; yet, ischemia continues to complicate femoral VA-ECMO [1]. We describe 3 consecutive patients who underwent cannulation for VA-ECMO by a side-arm graft sewn to the femoral artery (FA) that does not compromise LE perfusion. After exposure, an exclusion clamp is placed on the FA, and a longitudinal incision is made. An anastomosis of an 8-mm Gelweave Dacron graft (Vascutek, Scotland, UK) is made end-to-side to the FA with two layers of continuous 5– 0 Prolene sutures. The graft is tunneled inferiorly under the skin, remaining entirely in a subcutaneous position. The graft is attached to a ¼-inch ⫻ 3/8-inch tubing connector (Intersept, Medtronic Inc, Minneapolis, MN) outside the skin and subsequently connected to the ECMO arterial tubing (Fig 1). During decannulation, the graft is clamped close to the FA, divided, and oversewn with two layers of continuous 5– 0 Prolene sutures.
Case Reports Patient 1 A 15-year-old boy presented with cardiovascular collapse secondary to viral myocarditis. He was emergently given VA-ECMO by percutaneous cannulation with 17F right FA and 21F right femoral venous (FV) cannulas. After stabilization, he experienced decreased perfusion and Accepted for publication May 4, 2012. Address correspondence to Dr Alten, University of Alabama at Birmingham, 1600 7th Ave S, ACC 504, Birmingham, AL 35233; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Anastomosis of an 8-mm side-arm graft in an end-to-side fashion to the femoral artery, tunneled under the skin, and attached to a tubing connector, which is then connected to the arterial extracorporeal membrane oxygenation (ECMO) line.
absence of pulse in his right LE. Because of persistent ischemia, he underwent a side-arm graft anastomosis to the contralateral FA, as described earlier. The right FA cannula was removed, and distal perfusion normalized. The FA graft provided excellent flow to his upper body, as demonstrated by normal radial artery and cerebral near-infrared spectroscopy (cNIRS) saturations. He had no further ischemic or bleeding complications as result of either cannulation site, and weaning from ECMO on day 8 was successful.
Patient 2 A 22-year-old man with congenital aortic stenosis was admitted with worsening stenosis and decompensated heart failure. His condition became unstable, with frequent episodes of syncope and coronary ischemia, requiring VA-ECMO. Percutaneous cannulation was performed with 19F right FA and 21F right FV cannulas with the patient under moderate sedation. After stabilization, he underwent general anesthesia for revision of the arterial cannulation to a side-arm graft; the initial arterial cannula was removed. The next day a large hematoma was noted at the cannulation site; bedside exploration revealed diffuse oozing at the graft anastomosis suture line. Bleeding was controlled with pledgeted suture and a bovine pericardial patch to tamponade further oozing. He had no further bleeding complications and maintained excellent distal lower extremity perfusion. His radial artery saturations and cNIRS remained normal during ECMO support. On ECMO day 3, he underwent balloon dilatation of his aortic valve with improvement of his ventricular function, enabling successful weaning from ECMO the next day.
Patient 3 A 43-year-old man with tetralogy of Fallot presented for tricuspid valve replacement. He underwent cannulation 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.064
e112
CASE REPORT JACKSON ET AL SIDE-ARM GRAFTS FOR FEMORAL EXTRACORPOREAL MEMBRANE OXYGENATION CANNULATION
for cardiopulmonary bypass (CPB) with a left FA cannula. A long intraoperative course was complicated by severe bleeding. After weaning from CPB, he experienced low cardiac output and rapidly progressive lactic acidosis, requiring VA-ECMO support by a side-arm graft attached to the left FA and a 25F FV cannula. Severe postoperative bleeding precluded the initial use of heparin; the cannulation site was packed with sponges, and the skin temporarily closed with a bovine pericardial patch. He experienced no further bleeding complications and maintained normal LE perfusion. Weaning from ECMO was successful day three.
Comment The femoral vessels are frequently cannulated for VAECMO because they offer relatively easy access to the central circulation and are associated with decreased bleeding and neurologic complications. Because the arterial cannula may approach the diameter of the FA, distal leg perfusion can become compromised. The incidence of LE ischemia ranges from 10% to 50% in patients with FA cannulation [1, 2]. The procedure in this report was adapted from the axillary artery CPB cannulation technique used by our cardiovascular surgeons. The success of this technique in rescuing our first patient from LE ischemia led us to explore it as our primary method of FA ECMO cannulation. We believe that ischemia related to cannula obstruction could be eliminated with this side-arm graft technique. All 3 patients demonstrated excellent LE perfusion (warm and pink), with easily palpable pulses once contractility returned. Historically, our patients whose FAs were directly cannulated had a temperature difference between the feet and rarely had palpable LE pulses. Other techniques are reported to decrease the risk of distal leg ischemia seen in femoral VA-ECMO; most involve variations of DPCs that can be percutaneously or surgically placed distal to the ECMO cannulation site [3– 6]. Investigators have still reported ischemia and tissue damage with their use, side effects of their placement, or both [1]. Our side-arm graft technique avoids intraluminal cannulas entirely, which should nearly eliminate the occurrence of LE ischemia in addition to allowing antegrade and retrograde blood flow. All 3 patients had normal retrograde (upper body) oxygen delivery as measured by cNIRS monitoring and measurements of radial arterial and superior vena cava venous saturation. The anastomosis of prosthetic vascular grafts to the FA has previously been described for CPB [7] and ECMO support [8]. Although they did not describe it in detail, Doll and colleagues [8] mentioned performing anastomosis of a 6-mm Hemashield prosthesis to the FA in a review of their vast ECMO experience. They observed decreased ischemia after the change from percutaneous cannulation, but it is not clear how many patients under-
Ann Thorac Surg 2012;94:e111–2
went cannulation in this manner and whether increased bleeding or other complications resulted. One advantage of femoral cannulation is that the vessels are easily cannulated percutaneously, offering the potential for emergent access. Our technique requires cutdown exposure and arteriotomy of the FA, increasing cannulation time and bleeding risks in comparison with the percutaneous technique. The second patient highlighted this limitation, given that he had significant bleeding at the anastomosis site, requiring reexploration. The potential for increased risk of bleeding and infection (foreign material) makes it necessary to delineate patient populations that may benefit most from this cannulation technique. Patients with smaller vessels likely to be occluded by arterial cannulas [4] (children, thin adults, peripheral artery disease [2]), patients in whom ischemia develops after percutaneous cannulation, or patients who undergo cannulation in the operating room with vessels already exposed for CPB (similar to our third patient) all may be attractive candidates for this approach. In conclusion, our variation of a side-arm graft to establish FA access is effective in reversing or preventing distal LE ischemia, or both, associated with femoral VA-ECMO. Prospective studies are necessary to determine whether this technique has a sufficiently favorable side effect profile compared with percutaneous cannulation to warrant its prophylactic use in all patients.
References 1. Gander JW, Fisher JC, Reichstein AR, et al. Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem. J Pediatr Surg 2010;45:2136 – 40. 2. Bisdas T, Beutel G, Warnecke G, et al. Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. Ann Thorac Surg 2011;92:626–31. 3. Russo CF, Cannata A, Vitali E, Lanfranconi M. Prevention of limb ischemia and edema during peripheral venoarterial extracorporeal membrane oxygenation in adults. J Card Surg 2009;24:185–7. 4. Haley MJ, Fisher JC, Ruiz-Elizalde AR, Stolar CJ, Morrissehy NJ, Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child. J Pediatr Surg 2009;44:437– 40. 5. Greason KL, Hemp JR, Maxwell JM, Fetter JE, Moreno-Cabral RJ. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation. Ann Thorac Surg 1995;60:209 –10. 6. Kasirajan V, Simmons I, King J, Shumaker MD, DeAnda A, Higgins RS. Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation. Perfusion 2002;17:427– 8. 7. Vander Salm TJ. Prevention of lower extremity ischemia during cardiopulmonary bypass via femoral cannulation. Ann Thorac Surg 1997;63:251–2. 8. Doll N, Kiaii B, Borger M, et al. Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock. Ann Thorac Surg 2004;77:151–7; discussion 157.