Occurrence, Predictors, and Management of Late Vascular Complications following Extracorporeal Membrane Oxygenation
Juliet Blakeslee-Carter, Benjamin Pearce, Emily Spangler, Adam W Beck, Graeme E McFarland
University of Alabama at Birmingham, Birmingham, AL
Introduction:Vascular complications (VC) associated with ECMO during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late vascular complications following ECMO; as such, this study aims to assesses occurrence and management practices of late VC following discharge. Methods:A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO in 2019-2020. Primary outcomes were rate and categorization of late VC, defined as any vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Results: A total of 229 patients were identified, of which, 50.6% survived until discharge (Figure 1). Late VC occurred in 9.5% of the surviving cohort (n=11/116); with a median time until presentation of 150 days (IQR 68-263) (Table 1). The most common late VC was chronic limb threatening ischemia (CLTI) (n=6, 55%), followed by infection (n=5, 45%). The majority of the patients with late VC presented urgently to the emergency department (n=6, 54.5%), while 45.5% (n=5) were sent from clinic for elective interventions. The most common intervention performed for management of late VC was bypass (n=5, 45.4%). Amputations were performed in 27.2% (n=3/11) of patients presenting with late VC. The majority of patients presenting with late VC had initially been cannulated for peripheral-VA ECMO (n=9, 81.8%), while 1 patient (9%) was cannulated for central-VA and 1 patient (9%) was cannulated for peripheral-VV ECMO. Average ECMO run time in those with late VC was 16.4±20 days, which was not significantly different compared to those without late VC. Median ipsilateral ECMO cannula in patients with late VC was 18 Fr (IQR 17-21). Prior VC during index hospitalization were seen in 81.8% (n=9/11) of patients returning with late VC; the most common prior index VC was acute limb ischemia (n=6/9). Odds for late VC were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal-cardio-pulmonary resuscitation (E-CRP) (OR 6.7, 95%-CI 1.3-13.1, p=0.02) and in cases were patient had experienced an index VC during index hospitalization (OR 9.5, 95%-CI 3.9-16.2, p<0.001). Compared to index VC, infectious etiology was notably more prevalent and endovascular management more frequently utilized in late VC. Conclusion:Late VC was less prevalent than index hospitalization VC. Majority of patients with late VC were initially cannulated for peripheral-VA ECMO and had experienced index hospitalization VC. Odds for late VC were significantly increased in patients who were cannulated as part of E-CRP or had experienced VC during index hospitalization. Majority of patients with late VC presented in an urgent fashion, and compared to early index VC, late occurrence was more likely to be infectious in nature and was treated with notably different management patterns. 
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