Document Detail


Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.
MedLine Citation:
PMID:  21034934     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
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.
Authors:
Jeffrey W Gander; Jason C Fisher; Ari R Reichstein; Erica R Gross; Gudrun Aspelund; William Middlesworth; Charles J Stolar
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Publication Detail:
Type:  Comparative Study; Journal Article    
Journal Detail:
Title:  Journal of pediatric surgery     Volume:  45     ISSN:  1531-5037     ISO Abbreviation:  J. Pediatr. Surg.     Publication Date:  2010 Nov 
Date Detail:
Created Date:  2010-11-01     Completed Date:  2010-11-30     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0052631     Medline TA:  J Pediatr Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  2136-40     Citation Subset:  IM    
Copyright Information:
Copyright © 2010 Elsevier Inc. All rights reserved.
Affiliation:
Department 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
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MeSH Terms
Descriptor/Qualifier:
Adolescent
Angiography
Catheterization, Peripheral / adverse effects*
Child
Child, Preschool
Extracorporeal Membrane Oxygenation / adverse effects,  methods*
Female
Femoral Artery
Follow-Up Studies
Heart Diseases / therapy
Humans
Incidence
Ischemia / diagnosis,  epidemiology,  etiology*
Leg / blood supply*
Male
New York / epidemiology
Prognosis
Retrospective Studies
Risk Factors
Young Adult

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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