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Abstract：
BACKGROUND: Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients\' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications.
METHODS: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models.
RESULTS: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar.
CONCLUSIONS: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.
METHODS: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models.
RESULTS: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar.
CONCLUSIONS: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.
摘要：
背景：脑灌注可能根据动脉插管部位而变化，并可能影响心脏切开术后体外生命支持（ECLS）中神经系统不良事件的发生率。当前的研究将患者的神经系统结局与三种常用的动脉插管策略进行了比较（主动脉与锁骨下/腋窝vs.股动脉），以评估每种ECLS配置是否与神经系统并发症的不同发生率相关。
方法：本回顾性研究，多中心（34个中心），观察性研究纳入了2000年1月至2020年12月期间需要进行心脏切开术后ECLS的成年人,该研究出现在心脏切开术后体外生命支持(PELS)研究数据库中.主动脉患者,比较锁骨下/腋下和股骨插管在复合神经系统终点（缺血性卒中，脑出血,脑水肿)。次要结局是总体住院死亡率，神经系统并发症是院内死亡的原因，和术后轻微的神经系统并发症（癫痫发作）。通过线性混合效应模型研究了插管与神经系统结局之间的关联。
结果：这项研究包括1897名患者，其中主动脉占26.5％（n=503），20.9%锁骨下/腋下（n=397）和52.6%股骨（n=997）插管。锁骨下/腋下组的高血压病史更为频繁，吸烟,糖尿病,以前的心肌梗塞，透析,外周动脉疾病和既往卒中。神经监测在所有组中都很少使用。在混合效应模型调整后，锁骨下/腋下的主要神经系统并发症更为常见（主动脉：n=79，15.8％；锁骨下/腋下：n=78，19.6％；股骨：n=118，11.9％；p<0.001）（OR1.53[95％CI1.02-2.31]，p=0.041)。癫痫发作在锁骨下/腋下（n=13，3.4％）比主动脉（n=9，1.8％）和股骨插管（n=12，1.3％，p=0.036)。主动脉插管后住院死亡率更高（主动脉：n=344，68.4％，锁骨下/腋下：n=223，56.2%，股骨：n=587，58.9%，p<0.001)，如Kaplan-Meier曲线所示。总之,神经系统死亡原因(主动脉：n=12，3.9%，锁骨下/腋下：n=14，6.6％，股骨：n=28，5.0%，p=0.433）相似。
结论：在PELS研究的分析中，锁骨下/腋下插管与较高的主要神经系统并发症和癫痫发作率相关。主动脉插管后住院死亡率较高，尽管这些患者的神经系统死亡原因发生率没有显着差异。这些结果鼓励对ECLS患者的神经系统并发症和神经监测使用保持警惕，尤其是锁骨下/腋下插管。
方法：本回顾性研究，多中心（34个中心），观察性研究纳入了2000年1月至2020年12月期间需要进行心脏切开术后ECLS的成年人,该研究出现在心脏切开术后体外生命支持(PELS)研究数据库中.主动脉患者,比较锁骨下/腋下和股骨插管在复合神经系统终点（缺血性卒中，脑出血,脑水肿)。次要结局是总体住院死亡率，神经系统并发症是院内死亡的原因，和术后轻微的神经系统并发症（癫痫发作）。通过线性混合效应模型研究了插管与神经系统结局之间的关联。
结果：这项研究包括1897名患者，其中主动脉占26.5％（n=503），20.9%锁骨下/腋下（n=397）和52.6%股骨（n=997）插管。锁骨下/腋下组的高血压病史更为频繁，吸烟,糖尿病,以前的心肌梗塞，透析,外周动脉疾病和既往卒中。神经监测在所有组中都很少使用。在混合效应模型调整后，锁骨下/腋下的主要神经系统并发症更为常见（主动脉：n=79，15.8％；锁骨下/腋下：n=78，19.6％；股骨：n=118，11.9％；p<0.001）（OR1.53[95％CI1.02-2.31]，p=0.041)。癫痫发作在锁骨下/腋下（n=13，3.4％）比主动脉（n=9，1.8％）和股骨插管（n=12，1.3％，p=0.036)。主动脉插管后住院死亡率更高（主动脉：n=344，68.4％，锁骨下/腋下：n=223，56.2%，股骨：n=587，58.9%，p<0.001)，如Kaplan-Meier曲线所示。总之,神经系统死亡原因(主动脉：n=12，3.9%，锁骨下/腋下：n=14，6.6％，股骨：n=28，5.0%，p=0.433）相似。
结论：在PELS研究的分析中，锁骨下/腋下插管与较高的主要神经系统并发症和癫痫发作率相关。主动脉插管后住院死亡率较高，尽管这些患者的神经系统死亡原因发生率没有显着差异。这些结果鼓励对ECLS患者的神经系统并发症和神经监测使用保持警惕，尤其是锁骨下/腋下插管。
