Fisser Christoph, Armbrüster Corina, Wiest Clemens, Philipp Alois, Foltan Maik, Lunz Dirk, Pfister Karin, Schneckenpointner Roland, Schmid Christof, Maier Lars S, Müller Thomas, Lubnow Matthias
Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.
Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany.
Front Med (Lausanne). 2022 Jul 28;9:960716. doi: 10.3389/fmed.2022.960716. eCollection 2022.
The aim of this study was to investigate the prevalence of arterial and venous complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) and its risk factors at the time of cannulation and during extracorporeal membrane oxygenation (ECMO) support and to assess vascular complications in association with decannulation.
Between January 2010 to January 2020, out of 1,030 eligible patients requiring VA-ECMO, 427 with analyzable vascular screening were included. Duplex sonography and/or CT scan after decannulation were used to screen for thrombosis and pulmonary embolism as well as arterial complications. Near-infrared spectrometry (NIRS) was established at the time of cannulation and was continuously monitored during the ECMO therapy.
The prevalence of venous complications was 27%. Thrombosis and pulmonary embolism were observed in 21 and 7% of patients, respectively. Pulmonary embolism was more frequently diagnosed in patients with thrombosis (22 vs. 3%, < 0.001). In multivariate analysis, cannulation in the jugular vein was determined as a risk factor for venous thrombosis in contrast to the extent of anticoagulation. The prevalence of arterial complications was 37%, mainly ischemia followed by bleeding, dissection, and compartment syndrome. Vascular surgery was necessary for 19% of the patients, of whome 1% required major amputations. A distal perfusion cannula (DPC) was implanted at cannulation in 24% of patients and secondarily in 16% of patients after cannulation as required during ECMO support. In the multivariate analysis, risk factors for leg ischemia at the time of cannulation were elevated D-dimers, lower NIRS on the cannulated leg, and lack of a DPC. The best discriminative parameter was the difference in NIRS between the non-cannulated leg and the cannulated leg. In contrast, during ECMO support, only the lack of a DPC was associated with leg ischemia. A similar rate of complications associated with decannulation, mainly arterial thrombosis, ischemia, or bleeding, was seen with percutaneous and surgical approaches (18 vs. 17%, = 0.295).
Patients requiring VA ECMO should be routinely screened for vascular complications. The decision to insert a DPC should be evaluated individually. However, NIRS monitoring of the cannulated leg and the non-cannulated leg is essential to identify the legs at risk for critical ischemia. As complications associated with decannulation were equally distributed between percutaneous and surgical approaches, the applied method may be chosen according to local experience.
本研究的目的是调查需要外周静脉 - 动脉体外膜肺氧合（VA ECMO）的患者中动脉和静脉并发症的发生率及其在插管时和体外膜肺氧合（ECMO）支持期间的危险因素，并评估与拔管相关的血管并发症。
2010年1月至2020年1月期间，在1030例需要VA - ECMO的符合条件的患者中，纳入了427例可进行血管筛查分析的患者。拔管后采用双功超声和/或CT扫描筛查血栓形成、肺栓塞以及动脉并发症。在插管时建立近红外光谱（NIRS），并在ECMO治疗期间持续监测。
静脉并发症的发生率为27%。分别在21%和7%的患者中观察到血栓形成和肺栓塞。肺栓塞在血栓形成患者中更常被诊断（22%对3%，P<0.001）。在多变量分析中，与抗凝程度相比，颈静脉插管被确定为静脉血栓形成的危险因素。动脉并发症的发生率为37%，主要是缺血，其次是出血、夹层和骨筋膜室综合征。19%的患者需要进行血管手术，其中1%需要进行大截肢。24%的患者在插管时植入了远端灌注导管（DPC），在ECMO支持期间根据需要有16%的患者在插管后再次植入。在多变量分析中，插管时腿部缺血的危险因素是D - 二聚体升高、插管侧腿部NIRS降低以及缺乏DPC。最佳判别参数是未插管侧腿部与插管侧腿部NIRS的差异。相比之下，在ECMO支持期间，只有缺乏DPC与腿部缺血相关。经皮和手术方法与拔管相关的并发症发生率相似，主要是动脉血栓形成、缺血或出血（18%对17%，P = 0.295）。
需要VA ECMO的患者应常规筛查血管并发症。是否插入DPC的决定应个体化评估。然而，对插管侧腿部和未插管侧腿部进行NIRS监测对于识别有严重缺血风险的腿部至关重要。由于与拔管相关的并发症在经皮和手术方法之间分布相同，可根据当地经验选择应用的方法。
