Characterizing Arterial Limb Complications Secondary to Veno-Arterial Extracorporeal Membrane Oxygenation
Mustafa A Khader, Katherine M Owsiany, Yash Dayal, Yazan M Duwayri, Mani A Daneshmand, Olamide Alabi
Emory University, Atlanta, GA
BACKGROUND-Prior studies have shown that use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be complicated by vascular complications. Specifically, arterial limb complications (ALC) have been reported as high as 40% in single-institution cohorts of VA-ECMO patients. ALC can range from minor issues requiring observation and medical management to major complications that lead to limb loss or even death. We sought to characterize predictors of ALC after VA-ECMO and, as well, to examine the association between ALC and mortality. METHODS-We performed a review of a prospectively maintained dataset of all patients initiated on VA-ECMO between January 2015 and October 2022 in a large multicenter academic healthcare network with a dedicated ECMO team. Sociodemographic data and ECMO-related factors were recorded. For the initial analysis, we used univariable and multivariable logistic regression to examine predictors of ALC. We then fit cox proportional hazard models to determine the association between ALC and in-hospital mortality as well as 1 year mortality. Statistical analysis was completed using IBM SPSS v29.0.
RESULTS-Among the 337 patients who were initiated on VA-ECMO during the study period, the median age was 54 (41-69), 61.4% (n= 207) were male, and 44.8% (n=151) identified as White race. There were 92 (27.3%) ALC recorded, of which 96.7% were managed by vascular surgery (63.0% were operative and 33.7% of these were nonoperative). Of note, only 4 (1.2%) patients had a major lower extremity amputation as a result of an ALC.
Factors that increased the likelihood of ALC include age under 65, obesity, female sex, transfer from a referring hospital, same side VA-ECMO cannulation, distal perfusion catheter (DPC) placement, tibial DPC placement, DPC size. Factors associated with decreased likelihood of ALC include age over 65, past medical history of heart failure, atrial fibrillation, or advanced kidney disease, VA-ECMO cannulation at our facility, and VA-ECMO cannulation at the bedside in our facility or in the operating room at our facility. No single factor was independently associated with ALC [Table 1]. After adjusting for sociodemographic and ECMO-specific factors, ALC was not significantly associated with in-hospital mortality (adjusted hazard ratio, aHR: 0.8, 95% CI 0.6-1.2) or 1 year mortality (aHR: 0.9, 95% CI 0.4-2.5) [Table 2].
CONCLUSION-Nearly one-quarter (27.3%) of our cohort had an ALC after VA-ECMO initiation and only 1.2% suffered limb loss. ALC secondary to VA-ECMO is not associated with mortality during the same hospital encounter or within 1 year. Determining the need and timing of DPC placement and perhaps considerations for arterial and venous positioning may prove useful in decreasing ALC.
Table 1: Multivariable analysis of the factors associated with arterial limb complications.
| Variable | Adjusted OR (95% CI) | p-value | |
| Age (Categorical) | ≤44 - REFERENT 45-64 ≥65 | 0.7 (0.2 - 2.0) | 0.49 |
| BMI (Categorical) | Non-Obese - REFERENT Obese | 1.2 (0.6 - 2.4) | 0.53 |
| Gender | Male - REFERENT Female | 0.8 (0.4 - 1.6) | 0.50 |
| Heart Failure | - | 0.7 (0.3 - 1.5) | 0.36 |
| Atrial Fibrillation | - | 0.3 (0.1 - 1.3) | 0.10 |
| Advanced Kidney Disease | - | 0.4 (0.1 - 1.7) | 0.23 |
| Transferred from? | Non-Transfer - REFERENT Affiliated Hospital Non-Affiliated Hospital | 1.4 (0.6 - 3.2) | 0.43 |
| ECMO Cannulation at EHC | No - REFERENT Yes | 0.6 (0.3 - 1.6) | 0.33 |
| Same Side Cannulation | - | 2.0 (0.9 - 3.9) | 0.066 |
| DPC placed | No - REFERENT At ECMO initiation After initiation | 2.6 (0.9 - 7.7) 3.2 (0.9 - 10.2) | 0.088 0.063 |
| DPC Site | Femoral - REFERENT Tibial | 4.3 (0.7 - 16.4) | 0.11 |
| DPC Size | - | 1.2 (0.9 - 1.6) | 0.33 |
Table 2. Cox regression analysis of the association between arterial limb complications and in-hospital and one-year mortality
| Variable | Unadjusted HR (95% CI) | p-value | Adjusted HR (95% CI) | p-value | |
| Arterial limb complication | In-hospital mortality | 0.9 (0.6 - 1.2) | 0.38 | 0.8 (0.6 - 1.2) | 0.29 |
| One-year Mortality | 1.1 (0.6 - 2.0) | 0.81 | 0.9 (0.4 - 2.5) | 0.89 |
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