Venous-Arteriovenous Cannulation for Adult Ecmo Patient With Cardiogenic Shock

PURPOSE: ECMO support for cardiac failure requires the placement of an intra-arterial cannula either in the carotid or femoral artery. As a consequence, end organ ischemia, either cerebral or lower extremity, is always a concern. Femoral artery cannulation would appear optimal but the concern with this mode of cannulation is being able to provide adequate retrograde cardiac support as well as upper body oxygenation. The use of V-AV cannulation would allow for adjustable cardiac and pulmonary support depending on the needs of the patient. We wished to review our institution's data to determine the safety and adequacy of support provided by this mode of cannulation. METHODS: A retrospective chart review was performed utilizing the University of Michigan ECMO Registry. All patients from 1989 to 2002 that were placed on arterial support were reviewed for patient demographics, diagnosis, complications and outcome. The data were analyzed using a stepwise logistic regression and student's t-test. RESULTS: There were 59 carotid and 68 femoral artery cannulations performed. Nineteen of the femoral cannulations utilized V-AV support. The patient demographics were not statistically different. Carotid cannulation was associated with a 15% incidence of ipsilateral stroke overall, and a 25% stroke rate in women. Femoral artery cannulation was associated with leg ischemia requiring the placement of a distal reperfusion cannula in 33.8% of patients. The development of limb ischemia occurred in 21.6% of men as compared to 48% of women (p = 0.02). Lower extremity limb loss or ischemic neuropathy occurred in 5 patients, likely due to delay in reperfusion. Overall survival was not dependent on the mode of cannulation. CONCLUSION: The use of V-AV cannulation for the adult patient with primary cardiac failure provides a very effective and flexible method of support without significant added morbidity due to the cannulation. Cardiac support can be titrated as needed with diversion of flow to the right atrium as function improves. Prompt placement of a distal reperfusion cannula can minimize distal limb complications.