Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.
Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.
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DOI：
10.1016/j.jpedsurg.2010.07.005
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发表时间：
2010-11
影响因子：
2.4
通讯作者：
Stolar, Charles J.
中科院分区：
文献类型：
--
作者：
Gander, Jeffrey W.;Fisher, Jason C.;Reichstein, Ari R.;Gross, Erica R.;Aspelund, Gudrun;Middlesworth, William;Stolar, Charles J.
体外循环生命支持组织登记数据证实，接受体外膜肺氧合（ECMO）支持的儿科患者数量正在增加。为了尽量减少颈动脉结扎的潜在神经学影响，股总动脉（CFA）经常被用于动脉插管。插管有可能阻碍流向下肢的血流，从而增加缺血和可能的肢体丧失。我们介绍了一家机构在静脉动脉（VA）ECMO中进行CFA插管的经验，并询问是否有任何预插管变量与严重肢体缺血的发生相关。我们回顾了2000年1月至2010年2月期间通过CFA插管接受VA ECMO支持的所有儿科患者。肢体缺血是主要变量。缺血组定义为由于下肢缺血而需要干预的患者。无缺血组患者未发生明显缺血。连续变量报告为中位数和四分位数范围，并使用Mann-Whitney U检验进行比较。使用χ2检验（Fisher精确检验）评估分类变量的差异。假设统计学显著性为P < .05。21例患者（年龄，2-22岁）通过CFA插管进行VA ECMO。21例患者中有11例（52%）发生了需要干预的严重缺血（缺血组）。在比较两组（缺血与无缺血）时，没有临床变量预测缺血的发生（表1）。在缺血组中，9/11例（81%）置入远端灌注导管（DPC）。DPC放置的并发症包括1例需要筋膜切开术的筋膜室综合征和1例需要间隔脚趾截肢的患者。缺血组2例未置入DPC的患者中，1例需要对损伤的股浅动脉进行血管重建，1例接受膝下截肢。缺血组的死亡率较低（27% vs 60%）。肢体缺血仍然是一个重要的问题，因为我们的患者中有一半以上发生了肢体缺血。由于无缺血组60%的死亡率可能掩盖了随后的缺血，因此真实的发病率可能并不清楚。虽然儿童有发生肢体缺血/丧失的风险，但在我们的系列研究中，没有变量可预测严重肢体缺血的发生。由于无法预测谁会发生肢体缺血，因此在插管时早期常规放置DPC可能是必要的。然而，DPC不能完全解决组织损失和发病率的问题。预防因VA ECMO的CFA插管导致的肢体缺血/丧失仍然是一个问题，可以从新策略中受益。
Extracorporeal Life Support Organization Registry data confirm that the number of pediatric patients being supported by extracorporeal membrane oxygenation (ECMO) is increasing. To minimize the potential neurologic effects of carotid artery ligation, the common femoral artery (CFA) is frequently being used for arterial cannulation. The cannula has the potential for obstructing flow to the lower limb, thus increasing ischemia and possible limb loss. We present a single institution’s experience with CFA cannulation for venoarterial (VA) ECMO and ask whether any precannulation variables correlate with the development of significant limb ischemia. We reviewed all pediatric patients who were supported by VA ECMO via CFA cannulation from January 2000 to February 2010. Limb ischemia was the primary variable. The ischemia group was defined as the patients requiring an intervention because of the development of lower extremity ischemia. The patients in the no-ischemia group did not develop significant ischemia. Continuous variables were reported as medians with interquartile ranges and compared using Mann-Whitney U tests. Differences in categorical variables were assessed using χ2 testing (Fisher’s Exact). Statistical significance was assumed at P < .05. Twenty-one patients (age, 2–22 years) were cannulated via the CFA for VA ECMO. Significant ischemia requiring intervention (ischemia group) occurred in 11 (52%) of 21. In comparing the 2 groups (ischemia vs no ischemia), no clinical variables predicted the development of ischemia (Table 1). In the ischemia group, 9 (81%) of 11 had a distal perfusion catheter (DPC) placed. Complications of DPC placement included one case of compartment syndrome requiring a fasciotomy and one patient requiring interval toe amputation. Of the 2 patients in the ischemia group who did not have a DPC placed, 1 required a vascular reconstruction of an injured superficial femoral artery and 1 underwent a below-the-knee amputation. Mortality was lower in the ischemia group (27% vs 60%). Limb ischemia remains a significant problem, as more than half of our patients developed it. The true incidence may not be known as a 60% mortality in the no-ischemia group could mask subsequent ischemia. Although children are at risk for developing limb ischemia/loss, no variable was predictive of the development of significant limb ischemia in our series. Because of the inability to predict who will develop limb ischemia, early routine placement of a DPC at the time of cannulation may be warranted. However, DPCs do not completely resolve issues around tissue loss and morbidity. Prevention of limb ischemia/loss because of CFA cannulation for VA ECMO continues to be a problem that could benefit from new strategies.
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影响因子：
4.2
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