背景:对于静脉-动脉体外膜氧合(ECMO),股动脉是优选的插管部位(股-股动脉:Vf-Af)。这导致逆行主动脉血流,这会增加左心室后负荷,并可能导致严重的肺水肿和心腔血栓形成。右腋窝动脉插管(股-腋窝:Vf-Aa)提供部分顺行主动脉血流,这可以防止一些并发症。本研究旨在比较VF-AA和VF-AF的90天死亡率和并发症发生率。
方法:回顾性纳入2013年至2019年在我院接受外周VA-ECMO治疗的连续心源性休克成年患者。排除标准为难治性心脏骤停,由于血管通路的变化,多次VA-ECMO植入,断奶失败,或ICU再入院。使用治疗加权的逆概率的统计方法来估计插管部位对结果的影响。主要终点是90天死亡率。次要终点是血管通路并发症,中风,和其他与逆行血流有关的并发症。使用逻辑回归分析估计结果。
结果:对534例患者进行了VA-ECMO。难治性心脏骤停患者(n=77(14%))和多次VA-ECMO支持的患者(n=92,(17%))被排除在外。在研究的333名患者中(n=209Vf-Aa;n=124VF-AF),VA-ECMO植入的主要指征是心脏切开术后(33%,n=109),扩张型心肌病(20%,n=66),心脏移植后(15%,n=50),急性心肌梗死(14%,n=46)和其他病因(18%,n=62)。SOFA评分中位数为9[7-11],90天的粗死亡率为53%(n=175)。IPTW之后,Vf-Aa和VF-AF组的90天死亡率相似(54%vs58%,IPTW-OR=0.84[0.54-1.29])。腋下动脉插管与局部感染明显减少相关(OR=0.21,95%CI:0.09-0.51),肢体缺血(OR=0.37,95%CI:0.17-0.84),肠缺血(OR=0.16,95%CI:0.05-0.51)和肺水肿(OR=0.52,95%CI:0.29-0.92)发作,但卒中发生率(OR=2.87,95%CI:1.08-7.62)高于股动脉插管。
结论:与VF-AF相比,腋窝插管与相似的90天死亡率相关.与腋窝动脉插管相关的高中风率需要进一步研究。
BACKGROUND: For veno-arterial extracorporeal membrane oxygenation (ECMO), the femoral artery is the preferred cannulation site (femoro-femoral: Vf-Af). This results in retrograde aortic flow, which increases the left ventricular afterload and can lead to severe pulmonary edema and thrombosis of the cardiac chambers. Right axillary artery cannulation (femoral-axillary: Vf-Aa) provides partial anterograde aortic flow, which may prevent some complications. This study aimed to compare the 90-day mortality and complication rates between VF-AA and VF-AF.
METHODS: Consecutive adult patients with cardiogenic shock who received peripheral VA-ECMO between 2013 and 2019 at our institution were retrospectively included. The exclusion criteria were refractory cardiac arrest, multiple VA-ECMO implantations due to vascular access changes, weaning failure, or ICU readmission. A statistical approach using inverse probability of treatment weighting was used to estimate the effect of the cannulation site on the outcomes. The primary endpoint was the 90-day mortality. The secondary endpoints were vascular access complications, stroke, and other complications related to retrograde blood flow. Outcomes were estimated using logistic regression analysis.
RESULTS: VA-ECMO was performed on 534 patients. Patients with refractory cardiac arrest (n = 77 (14%)) and those supported by multiple VA-ECMO (n = 92, (17%)) were excluded. Out of the 333 patients studied (n = 209 Vf-Aa; n = 124 VF-AF), the main indications for VA-ECMO implantation were post-cardiotomy (33%, n = 109), dilated cardiomyopathy (20%, n = 66), post-cardiac transplantation (15%, n = 50), acute myocardial infarction (14%, n = 46) and other etiologies (18%, n = 62). The median SOFA score was 9 [7-11], and the crude 90-day mortality rate was 53% (n = 175). After IPTW, the 90-day mortality was similar in the Vf-Aa and VF-AF groups (54% vs 58%, IPTW-OR = 0.84 [0.54-1.29]). Axillary artery cannulation was associated with significantly fewer local infections (OR = 0.21, 95% CI:0.09-0.51), limb ischemia (OR = 0.37, 95% CI:0.17-0.84), bowel ischemia (OR = 0.16, 95% CI:0.05-0.51) and pulmonary edema (OR = 0.52, 95% CI:0.29-0.92) episodes, but with a higher rate of stroke (OR = 2.87, 95% CI:1.08-7.62) than femoral artery cannulation.
CONCLUSIONS: Compared to VF-AF, axillary cannulation was associated with similar 90-day mortality rates. The high rate of stroke associated with axillary artery cannulation requires further investigation.