Advertisement
The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Subclavian versus femoral arterial cannulations during extracorporeal membrane oxygenation: A propensity-matched comparison

Published:January 08, 2022DOI:https://doi.org/10.1016/j.healun.2022.01.007

      Background

      During peripheral extracorporeal veno-arterial membrane oxygenation (VA-ECMO) support, subclavian arterial cannulation provides, in comparison to femoral arterial cannulation, an anterograde flow which may prevent from left ventricular (LV) distention and improve outcomes. We aimed to compare the effectiveness of subclavian cannulation to femoral cannulation in reducing LV overdistension consequences, hemostatic complications and mortality.

      Methods

      This retrospective study conducted in two intensive care units of the Lille academic hospitals from January 2013 to December 2019 included 372 non-moribund adult patients supported by VA-ECMO. The primary endpoint was a new onset of pulmonary edema (PO) or LV unloading. Secondary endpoints were myocardial recovery, serious bleeding (according to Extracorporeal Life Support Organization definition), thrombotic complications (a composite of stroke, cannulated limb or mesenteric ischemia, intracardiac or aortic-root thrombosis) and 28 day mortality. Differences in outcomes were analyzed using propensity score matching (PSM) and inverse probability of treatment weighting adjustment (IPTW).

      Results

      As compared to femoral cannulation (n = 320 patients), subclavian cannulation (n = 52 patients) did not reduce the occurrence of new onset of PO or LV unloading after PSM [HR 0.99 (95% CI 0.51–1.91)]. There was no other difference in outcomes in PSM cohort. In IPTW adjustment cohort, subclavian cannulation was associated with reduced recovery and increased serious bleeding with four accidental decannulations observed.

      Conclusion

      Subclavian artery cannulation was not associated with reduced LV distension related complications, thrombotic complications and 28 day mortality. Rather, it may increase serious bleeding and accidental decannulations, and reduce recovery. Therefore, subclavian cannulation should be limited to vascular accessibility issues.

      KEYWORDS

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Heart and Lung Transplantation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Extracorporeal Life Support Organization - ECMO and ECLS >Registry >Statistics >International Summary. Accessed January 2, 2018. Available at: https://www.elso.org/Registry/Statistics/InternationalSummary.aspx

        • Lorusso R
        • Whitman G
        • Milojevic M
        • et al.
        2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients.
        Ann Thorac Surg. 2021; 111: 327-369https://doi.org/10.1016/j.athoracsur.2020.07.009
        • Burkhoff D
        • Sayer G
        • Doshi D
        • Uriel N.
        Hemodynamics of mechanical circulatory support.
        J Am Coll Cardiol. 2015; 66: 2663-2674https://doi.org/10.1016/j.jacc.2015.10.017
        • Donker DW
        • Brodie D
        • Henriques JPS
        • Broomé M.
        Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions.
        Perfusion. 2019; 34: 98-105https://doi.org/10.1177/0267659118794112
        • Prasad A
        • Ghodsizad A
        • Brehm C
        • et al.
        Refractory pulmonary edema and upper body hypoxemia during veno-arterial extracorporeal membrane oxygenation-a case for atrial septostomy.
        Artif Organs. 2018; 42: 664-669https://doi.org/10.1111/aor.13082
        • Contento C
        • Battisti A
        • Agrò B
        • et al.
        A novel veno-arteriovenous extracorporeal membrane oxygenation with double pump for the treatment of Harlequin syndrome.
        Perfusion. 2020; 35: 65-72https://doi.org/10.1177/0267659120908409
        • Pasrija C
        • Bedeir K
        • Jeudy J
        • Kon ZN.
        Harlequin syndrome during venoarterial extracorporeal membrane oxygenation.
        Radiol Cardiothorac Imaging. 2019; 1https://doi.org/10.1148/ryct.2019190031
        • Buchtele N
        • Staudinger T
        • Schwameis M
        • et al.
        Feasibility and safety of watershed detection by contrast-enhanced ultrasound in patients receiving peripheral venoarterial extracorporeal membrane oxygenation: a prospective observational study.
        Critical Care. 2020; 24: 126https://doi.org/10.1186/s13054-020-02849-y
        • Mariscalco G
        • Salsano A
        • Fiore A
        • et al.
        Peripheral versus central extracorporeal membrane oxygenation for postcardiotomy shock: Multicenter registry, systematic review, and meta-analysis.
        J Thorac Cardiovasc Surg. 2020; 160: 1207-1216.e44https://doi.org/10.1016/j.jtcvs.2019.10.078
        • Wong JK
        • Melvin AL
        • Joshi DJ
        • et al.
        Cannulation-related complications on veno-arterial extracorporeal membrane oxygenation: prevalence and effect on mortality.
        Artif Organs. 2017; 41: 827-834https://doi.org/10.1111/aor.12880
        • Javidfar J
        • Brodie D
        • Costa J
        • et al.
        Subclavian artery cannulation for venoarterial extracorporeal membrane oxygenation.
        ASAIO Journal. 2012; 58: 494-498https://doi.org/10.1097/MAT.0b013e318268ea15
        • Ranney DN
        • Benrashid E
        • Meza JM
        • et al.
        Central cannulation as a viable alternative to peripheral cannulation in extracorporeal membrane oxygenation.
        Semin Thorac Cardiovasc Surg. 2017; 29: 188-195https://doi.org/10.1053/j.semtcvs.2017.02.007
        • von Elm E
        • Altman DG
        • Egger M
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Lancet. 2007; 370: 1453-1457https://doi.org/10.1016/S0140-6736(07)61602-X
        • Lequier L
        • Annich G
        • Al-Ibrahim O.
        ELSO anticoagulation guideline. 2014.
        The Extracorporeal Life Support Organization (ELSO). 2016; (Published online): 1-17
        • Austin PC.
        Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.
        Stat Med. 2009; 28: 3083-3107https://doi.org/10.1002/sim.3697
        • Austin PC
        • Lee DS
        • Fine JP.
        Introduction to the Analysis of Survival Data in the Presence of Competing Risks.
        Circulation. 2016; 133: 601-609https://doi.org/10.1161/CIRCULATIONAHA.115.017719
        • Austin PC.
        A comparison of 12 algorithms for matching on the propensity score.
        Stat Med. 2014; 33: 1057-1069https://doi.org/10.1002/sim.6004
        • Austin PC.
        Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies.
        Pharm Stat. 2011; 10: 150-161https://doi.org/10.1002/pst.433
        • Mattei A.
        Estimating and using propensity score in presence of missing background data: an application to assess the impact of childbearing on wellbeing.
        Stat Methods Appl. 2009; 18: 257-273https://doi.org/10.1007/s10260-007-0086-0
      2. Campion WM, Rubin D. Multiple Imputation for Nonresponse in Surveys. Published online 1989. doi:10.2307/3172772

        • Numata S
        • Itatani K
        • Kanda K
        • et al.
        Blood flow analysis of the aortic arch using computational fluid dynamics.
        Eur J Cardiothorac Surg. 2016; 49: 1578-1585https://doi.org/10.1093/ejcts/ezv459
      3. Resident, Dept. of Anatomy, Seth G S Medical College, Parel, Mumbai, India., Chhabra K, Saini K, Assistant Professor, Dept. of Anatomy, Shri Bhausaheb Hire Govt. Medical College, Dhule, India. Morphometric study of arch of aorta and its branches. IJAR. 2015;3:1079-1083. doi:10.16965/ijar.2015.168

        • Pappalardo F
        • Schulte C
        • Pieri M
        • et al.
        Concomitant implantation of Impella on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock.
        Eur J Heart Fail. 2017; 19: 404-412https://doi.org/10.1002/ejhf.668
        • Vallabhajosyula S
        • O'Horo JC
        • Antharam P
        • et al.
        Concomitant intra-aortic balloon pump use in cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation.
        Circ Cardiovasc Interv. 2018; 11e006930https://doi.org/10.1161/CIRCINTERVENTIONS.118.006930
        • Wang D
        • Chao V
        • Yap KH
        • Tan TE.
        Does concurrent use of intra-aortic balloon pumps improve survival in patients with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation?.
        Interact Cardiovasc Thorac Surg. 2020; 30: 312-315https://doi.org/10.1093/icvts/ivz256
        • Al-Fares AA
        • Randhawa VK
        • Englesakis M
        • et al.
        Optimal strategy and timing of left ventricular venting during veno-arterial extracorporeal life support for adults in cardiogenic shock: a systematic review and meta-analysis.
        Circ Heart Fail. 2019; 12e006486https://doi.org/10.1161/CIRCHEARTFAILURE.119.006486
        • Cevasco M
        • Takayama H
        • Ando M
        • Garan AR
        • Naka Y
        • Takeda K.
        Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation.
        J Thorac Dis. 2019; 11: 1676-1683https://doi.org/10.21037/jtd.2019.03.29
        • Schrage B
        • Becher PM
        • Bernhardt A
        • et al.
        Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation: results from an international, multicenter cohort study.
        Circulation. 2020; 142: 2095-2106https://doi.org/10.1161/CIRCULATIONAHA.120.048792
        • Aubron C
        • DePuydt J
        • Belon F
        • et al.
        Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation.
        Ann Intensive Care. 2016; 6: 97https://doi.org/10.1186/s13613-016-0196-7
        • Guimbretière G
        • Anselmi A
        • Roisne A
        • et al.
        Prognostic impact of blood product transfusion in VA and VV ECMO.
        Perfusion. 2018; (Published online November 16)267659118814690https://doi.org/10.1177/0267659118814690
        • Mazzeffi MA
        • Tanaka K
        • Roberts A
        • et al.
        Bleeding, thrombosis, and transfusion with two heparin anticoagulation protocols in venoarterial ECMO patients.
        J Cardiothorac Vasc Anesth. 2019; 33: 1216-1220https://doi.org/10.1053/j.jvca.2018.07.045
        • Chamogeorgakis T
        • Lima B
        • Shafii AE
        • et al.
        Outcomes of axillary artery side graft cannulation for extracorporeal membrane oxygenation.
        J Thorac Cardiovasc Surg. 2013; 145: 1088-1092https://doi.org/10.1016/j.jtcvs.2012.08.070