Table_7_Arterial and venous vascular complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation.DOCX

IntroductionThe 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.
Material and methodsBetween 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.
ResultsThe 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%, p < 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%, p = 0.295).
ConclusionPatients 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.

引言
本研究旨在探讨需接受外周静脉-动脉体外膜肺氧合（VA ECMO）的患者发生动脉与静脉并发症的患病率，以及置管时与体外膜肺氧合（ECMO）支持期间的相关危险因素，并评估与拔管相关的血管并发症。

材料与方法
2010年1月至2020年1月期间，在1030例符合纳入标准的需接受VA ECMO治疗的患者中，最终纳入427例可进行血管筛查数据分析的患者。采用拔管后双功超声（duplex sonography）和/或计算机断层扫描（CT）筛查血栓形成、肺栓塞及动脉并发症。置管时即启动近红外光谱法（NIRS）监测，并在ECMO治疗期间持续监测。

结果
静脉并发症患病率为27%。分别有21%和7%的患者发生血栓形成与肺栓塞。合并血栓形成的患者中肺栓塞诊断率更高（22% vs. 3%，p<0.001）。多因素分析显示，与抗凝强度相比，经颈静脉置管是静脉血栓形成的危险因素。动脉并发症患病率为37%，以缺血最为常见，其次为出血、夹层与骨筋膜室综合征。19%的患者需接受血管外科手术，其中1%需行大型截肢术。24%的患者在置管时即植入远端灌注导管（DPC），另有16%的患者在置管后根据ECMO支持期间的临床需求二期植入该导管。多因素分析显示，置管时发生下肢缺血的危险因素包括D-二聚体升高、置管侧下肢近红外光谱值偏低以及未植入DPC。最佳判别参数为未置管侧与置管侧下肢的近红外光谱差值。与之相反，在ECMO支持期间，仅未植入DPC与下肢缺血相关。经皮途径与外科途径拔管的相关并发症发生率相近，主要并发症为动脉血栓形成、缺血或出血（18% vs. 17%，p=0.295）。

结论
需接受VA ECMO治疗的患者应常规筛查血管并发症。植入远端灌注导管（DPC）的决策应进行个体化评估。然而，对置管侧与未置管侧下肢进行近红外光谱法（NIRS）监测，对于识别存在严重缺血风险的肢体至关重要。由于经皮与外科拔管途径的并发症发生率无显著差异，临床可根据当地经验选择合适的拔管方式。