Department of Cardiovascular and Thoracic Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, 47-83, Boulevard de l'hopital, Paris, 75013, France.
Sorbonne Université, AP-HP, Hôpital Pitié-Salpêtrière, Département Biostatistique Santé Publique Et Information Médicale, Unité de Recherche Clinique PSL-CFX, Centre de Pharmacoépidémiologie (Cephepi), CIC-1421, Paris, France.
Intensive Care Med. 2018 Dec;44(12):2153-2161. doi: 10.1007/s00134-018-5442-z. Epub 2018 Nov 14.
Femoral artery surgical cannulation is the reference for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults. However, the less invasive percutaneous approach has been associated with lower rates of complications. This retrospective study compared complication rates and overall survival in a large series of patients who received surgical or percutaneous peripheral VA-ECMO.
All consecutive patients implanted with VA-ECMO between January 2015 and December 2017 in a high ECMO-volume university hospital were included. Surgical cannulation was the only approach until late 2016 after which the percutaneous approach became the first line strategy. Propensity score framework analyzes were used to compare outcomes of percutaneous and surgical groups while controlling for confounders.
Among the 814 patients who received VA-ECMO (485 surgical and 329 percutaneous), propensity-score matching selected 266 unique pairs of patients with similar characteristics. Percutaneous cannulation was associated with fewer local infections (16.5% versus 27.8%, p = 0.001), similar rates of limb ischemia (8.6% versus 12.4%, p = 0.347) and sensory-motor complications (2.6% versus 2.3%, p = 0.779) and improved 30-day survival (63.8% versus 56.3%, p = 0.034). However, more vascular complications following decannulation (14.7% versus 3.4%, p < 0.001), mainly persistent bleeding requiring surgical revision (9.4% vs. 1.5%, p < 0.001), occurred after percutaneous cannulation.
Compared to the surgical approach, percutaneous cannulation for peripheral VA-ECMO was associated with fewer local infections, similar rates of ischemia and sensory-motor complications and improved 30-day survival. The higher rate of vascular complications following decannulation suggests that improvements in cannula removal techniques are needed to further improve patients' outcomes after percutaneous cannulation.
股动脉外科插管是成人静脉-动脉体外膜肺氧合（VA-ECMO）的参考标准。然而，创伤较小的经皮方法与较低的并发症发生率相关。这项回顾性研究比较了在一家高 ECMO 量大学医院接受外科或经皮外周 VA-ECMO 的大量患者的并发症发生率和总体生存率。
纳入 2015 年 1 月至 2017 年 12 月期间在一家高 ECMO 量大学医院植入 VA-ECMO 的所有连续患者。直到 2016 年底，外科插管是唯一的方法，此后经皮方法成为一线策略。使用倾向评分框架分析来比较经皮组和外科组的结果，同时控制混杂因素。
在接受 VA-ECMO 的 814 名患者中（485 名外科和 329 名经皮），倾向评分匹配选择了 266 对具有相似特征的独特患者。经皮插管与较少的局部感染（16.5%对 27.8%，p=0.001）、相似的肢体缺血（8.6%对 12.4%，p=0.347）和感觉运动并发症（2.6%对 2.3%，p=0.779）发生率以及提高 30 天生存率（63.8%对 56.3%，p=0.034）相关。然而，经皮插管后，在拔管后更常见血管并发症（14.7%对 3.4%，p<0.001），主要是需要手术修复的持续性出血（9.4%对 1.5%，p<0.001）。
与外科方法相比，经皮外周 VA-ECMO 插管与较少的局部感染、相似的缺血和感觉运动并发症发生率以及提高 30 天生存率相关。拔管后血管并发症发生率较高表明需要改进插管去除技术，以进一步改善经皮插管后的患者预后。
