Portal de Periódicos da CAPES

Side-Arm Grafts for Femoral Extracorporeal Membrane Oxygenation Cannulation

2012; Elsevier BV; Volume: 94; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2012.05.064

1552-6259

Kimberly Jackson, Joseph G. Timpa, R Britt McILwain, Carlisle O’Meara, James K. Kirklin, Santiago Borasino, Jeffrey A. Alten,

Central Venous Catheters and Hemodialysis

Lower extremity ischemia is an important source of morbidity with femoral venoarterial extracorporeal membrane oxygenation support. We describe our experience with the use of a side-arm graft sewn to the femoral artery that facilitates adequate extracorporeal membrane oxygenation flow while preventing lower extremity ischemia. Lower extremity ischemia is an important source of morbidity with femoral venoarterial extracorporeal membrane oxygenation support. We describe our experience with the use of a side-arm graft sewn to the femoral artery that facilitates adequate extracorporeal membrane oxygenation flow while preventing lower extremity ischemia. The femoral vessels are the preferred site for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults and older children because of the decreased incidence of neurologic complications, ease of cannulation, and decreased bleeding when percutaneous techniques are used. Lower extremity (LE) ischemia is a complication of femoral VA-ECMO, with the potential for severe sequelae, including tissue loss and amputation [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]. Alternative techniques, such as distal perfusion catheters (DPC), have been developed to improve the flow distal to the arterial cannula [3Russo C.F. Cannata A. Vitali E. Lanfranconi M. Prevention of limb ischemia and edema during peripheral venoarterial extracorporeal membrane oxygenation in adults.J Card Surg. 2009; 24: 185-187Crossref PubMed Scopus (32) Google Scholar, 4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 5Greason K.L. Hemp J.R. Maxwell J.M. Fetter J.E. Moreno-Cabral R.J. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation.Ann Thorac Surg. 1995; 60: 209-210PubMed Scopus (63) Google Scholar, 6Kasirajan V. Simmons I. King J. Shumaker M.D. DeAnda A. Higgins R.S. Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation.Perfusion. 2002; 17: 427-428Crossref PubMed Scopus (26) Google Scholar]; yet, ischemia continues to complicate femoral VA-ECMO [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. We describe 3 consecutive patients who underwent cannulation for VA-ECMO by a side-arm graft sewn to the femoral artery (FA) that does not compromise LE perfusion.After exposure, an exclusion clamp is placed on the FA, and a longitudinal incision is made. An anastomosis of an 8-mm Gelweave Dacron graft (Vascutek, Scotland, UK) is made end-to-side to the FA with two layers of continuous 5–0 Prolene sutures. The graft is tunneled inferiorly under the skin, remaining entirely in a subcutaneous position. The graft is attached to a ¼-inch × 3/8-inch tubing connector (Intersept, Medtronic Inc, Minneapolis, MN) outside the skin and subsequently connected to the ECMO arterial tubing (Fig 1). During decannulation, the graft is clamped close to the FA, divided, and oversewn with two layers of continuous 5–0 Prolene sutures.Case ReportsPatient 1A 15-year-old boy presented with cardiovascular collapse secondary to viral myocarditis. He was emergently given VA-ECMO by percutaneous cannulation with 17F right FA and 21F right femoral venous (FV) cannulas. After stabilization, he experienced decreased perfusion and absence of pulse in his right LE. Because of persistent ischemia, he underwent a side-arm graft anastomosis to the contralateral FA, as described earlier. The right FA cannula was removed, and distal perfusion normalized. The FA graft provided excellent flow to his upper body, as demonstrated by normal radial artery and cerebral near-infrared spectroscopy (cNIRS) saturations. He had no further ischemic or bleeding complications as result of either cannulation site, and weaning from ECMO on day 8 was successful.Patient 2A 22-year-old man with congenital aortic stenosis was admitted with worsening stenosis and decompensated heart failure. His condition became unstable, with frequent episodes of syncope and coronary ischemia, requiring VA-ECMO. Percutaneous cannulation was performed with 19F right FA and 21F right FV cannulas with the patient under moderate sedation. After stabilization, he underwent general anesthesia for revision of the arterial cannulation to a side-arm graft; the initial arterial cannula was removed. The next day a large hematoma was noted at the cannulation site; bedside exploration revealed diffuse oozing at the graft anastomosis suture line. Bleeding was controlled with pledgeted suture and a bovine pericardial patch to tamponade further oozing. He had no further bleeding complications and maintained excellent distal lower extremity perfusion. His radial artery saturations and cNIRS remained normal during ECMO support. On ECMO day 3, he underwent balloon dilatation of his aortic valve with improvement of his ventricular function, enabling successful weaning from ECMO the next day.Patient 3A 43-year-old man with tetralogy of Fallot presented for tricuspid valve replacement. He underwent cannulation for cardiopulmonary bypass (CPB) with a left FA cannula. A long intraoperative course was complicated by severe bleeding. After weaning from CPB, he experienced low cardiac output and rapidly progressive lactic acidosis, requiring VA-ECMO support by a side-arm graft attached to the left FA and a 25F FV cannula. Severe postoperative bleeding precluded the initial use of heparin; the cannulation site was packed with sponges, and the skin temporarily closed with a bovine pericardial patch. He experienced no further bleeding complications and maintained normal LE perfusion. Weaning from ECMO was successful day three.CommentThe femoral vessels are frequently cannulated for VA-ECMO because they offer relatively easy access to the central circulation and are associated with decreased bleeding and neurologic complications. Because the arterial cannula may approach the diameter of the FA, distal leg perfusion can become compromised. The incidence of LE ischemia ranges from 10% to 50% in patients with FA cannulation [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar].The procedure in this report was adapted from the axillary artery CPB cannulation technique used by our cardiovascular surgeons. The success of this technique in rescuing our first patient from LE ischemia led us to explore it as our primary method of FA ECMO cannulation. We believe that ischemia related to cannula obstruction could be eliminated with this side-arm graft technique. All 3 patients demonstrated excellent LE perfusion (warm and pink), with easily palpable pulses once contractility returned. Historically, our patients whose FAs were directly cannulated had a temperature difference between the feet and rarely had palpable LE pulses.Other techniques are reported to decrease the risk of distal leg ischemia seen in femoral VA-ECMO; most involve variations of DPCs that can be percutaneously or surgically placed distal to the ECMO cannulation site [3Russo C.F. Cannata A. Vitali E. Lanfranconi M. Prevention of limb ischemia and edema during peripheral venoarterial extracorporeal membrane oxygenation in adults.J Card Surg. 2009; 24: 185-187Crossref PubMed Scopus (32) Google Scholar, 4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 5Greason K.L. Hemp J.R. Maxwell J.M. Fetter J.E. Moreno-Cabral R.J. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation.Ann Thorac Surg. 1995; 60: 209-210PubMed Scopus (63) Google Scholar, 6Kasirajan V. Simmons I. King J. Shumaker M.D. DeAnda A. Higgins R.S. Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation.Perfusion. 2002; 17: 427-428Crossref PubMed Scopus (26) Google Scholar]. Investigators have still reported ischemia and tissue damage with their use, side effects of their placement, or both [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. Our side-arm graft technique avoids intraluminal cannulas entirely, which should nearly eliminate the occurrence of LE ischemia in addition to allowing antegrade and retrograde blood flow. All 3 patients had normal retrograde (upper body) oxygen delivery as measured by cNIRS monitoring and measurements of radial arterial and superior vena cava venous saturation.The anastomosis of prosthetic vascular grafts to the FA has previously been described for CPB [7Vander Salm T.J. Prevention of lower extremity ischemia during cardiopulmonary bypass via femoral cannulation.Ann Thorac Surg. 1997; 63: 251-252Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar] and ECMO support [8Doll N. Kiaii B. Borger M. et al.Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.Ann Thorac Surg. 2004; 77 (discussion 157): 151-157Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar]. Although they did not describe it in detail, Doll and colleagues [8Doll N. Kiaii B. Borger M. et al.Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.Ann Thorac Surg. 2004; 77 (discussion 157): 151-157Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar] mentioned performing anastomosis of a 6-mm Hemashield prosthesis to the FA in a review of their vast ECMO experience. They observed decreased ischemia after the change from percutaneous cannulation, but it is not clear how many patients underwent cannulation in this manner and whether increased bleeding or other complications resulted.One advantage of femoral cannulation is that the vessels are easily cannulated percutaneously, offering the potential for emergent access. Our technique requires cutdown exposure and arteriotomy of the FA, increasing cannulation time and bleeding risks in comparison with the percutaneous technique. The second patient highlighted this limitation, given that he had significant bleeding at the anastomosis site, requiring reexploration. The potential for increased risk of bleeding and infection (foreign material) makes it necessary to delineate patient populations that may benefit most from this cannulation technique. Patients with smaller vessels likely to be occluded by arterial cannulas [4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar] (children, thin adults, peripheral artery disease [2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]), patients in whom ischemia develops after percutaneous cannulation, or patients who undergo cannulation in the operating room with vessels already exposed for CPB (similar to our third patient) all may be attractive candidates for this approach.In conclusion, our variation of a side-arm graft to establish FA access is effective in reversing or preventing distal LE ischemia, or both, associated with femoral VA-ECMO. Prospective studies are necessary to determine whether this technique has a sufficiently favorable side effect profile compared with percutaneous cannulation to warrant its prophylactic use in all patients. The femoral vessels are the preferred site for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults and older children because of the decreased incidence of neurologic complications, ease of cannulation, and decreased bleeding when percutaneous techniques are used. Lower extremity (LE) ischemia is a complication of femoral VA-ECMO, with the potential for severe sequelae, including tissue loss and amputation [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]. Alternative techniques, such as distal perfusion catheters (DPC), have been developed to improve the flow distal to the arterial cannula [3Russo C.F. Cannata A. Vitali E. Lanfranconi M. Prevention of limb ischemia and edema during peripheral venoarterial extracorporeal membrane oxygenation in adults.J Card Surg. 2009; 24: 185-187Crossref PubMed Scopus (32) Google Scholar, 4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 5Greason K.L. Hemp J.R. Maxwell J.M. Fetter J.E. Moreno-Cabral R.J. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation.Ann Thorac Surg. 1995; 60: 209-210PubMed Scopus (63) Google Scholar, 6Kasirajan V. Simmons I. King J. Shumaker M.D. DeAnda A. Higgins R.S. Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation.Perfusion. 2002; 17: 427-428Crossref PubMed Scopus (26) Google Scholar]; yet, ischemia continues to complicate femoral VA-ECMO [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. We describe 3 consecutive patients who underwent cannulation for VA-ECMO by a side-arm graft sewn to the femoral artery (FA) that does not compromise LE perfusion. After exposure, an exclusion clamp is placed on the FA, and a longitudinal incision is made. An anastomosis of an 8-mm Gelweave Dacron graft (Vascutek, Scotland, UK) is made end-to-side to the FA with two layers of continuous 5–0 Prolene sutures. The graft is tunneled inferiorly under the skin, remaining entirely in a subcutaneous position. The graft is attached to a ¼-inch × 3/8-inch tubing connector (Intersept, Medtronic Inc, Minneapolis, MN) outside the skin and subsequently connected to the ECMO arterial tubing (Fig 1). During decannulation, the graft is clamped close to the FA, divided, and oversewn with two layers of continuous 5–0 Prolene sutures. Case ReportsPatient 1A 15-year-old boy presented with cardiovascular collapse secondary to viral myocarditis. He was emergently given VA-ECMO by percutaneous cannulation with 17F right FA and 21F right femoral venous (FV) cannulas. After stabilization, he experienced decreased perfusion and absence of pulse in his right LE. Because of persistent ischemia, he underwent a side-arm graft anastomosis to the contralateral FA, as described earlier. The right FA cannula was removed, and distal perfusion normalized. The FA graft provided excellent flow to his upper body, as demonstrated by normal radial artery and cerebral near-infrared spectroscopy (cNIRS) saturations. He had no further ischemic or bleeding complications as result of either cannulation site, and weaning from ECMO on day 8 was successful.Patient 2A 22-year-old man with congenital aortic stenosis was admitted with worsening stenosis and decompensated heart failure. His condition became unstable, with frequent episodes of syncope and coronary ischemia, requiring VA-ECMO. Percutaneous cannulation was performed with 19F right FA and 21F right FV cannulas with the patient under moderate sedation. After stabilization, he underwent general anesthesia for revision of the arterial cannulation to a side-arm graft; the initial arterial cannula was removed. The next day a large hematoma was noted at the cannulation site; bedside exploration revealed diffuse oozing at the graft anastomosis suture line. Bleeding was controlled with pledgeted suture and a bovine pericardial patch to tamponade further oozing. He had no further bleeding complications and maintained excellent distal lower extremity perfusion. His radial artery saturations and cNIRS remained normal during ECMO support. On ECMO day 3, he underwent balloon dilatation of his aortic valve with improvement of his ventricular function, enabling successful weaning from ECMO the next day.Patient 3A 43-year-old man with tetralogy of Fallot presented for tricuspid valve replacement. He underwent cannulation for cardiopulmonary bypass (CPB) with a left FA cannula. A long intraoperative course was complicated by severe bleeding. After weaning from CPB, he experienced low cardiac output and rapidly progressive lactic acidosis, requiring VA-ECMO support by a side-arm graft attached to the left FA and a 25F FV cannula. Severe postoperative bleeding precluded the initial use of heparin; the cannulation site was packed with sponges, and the skin temporarily closed with a bovine pericardial patch. He experienced no further bleeding complications and maintained normal LE perfusion. Weaning from ECMO was successful day three. Patient 1A 15-year-old boy presented with cardiovascular collapse secondary to viral myocarditis. He was emergently given VA-ECMO by percutaneous cannulation with 17F right FA and 21F right femoral venous (FV) cannulas. After stabilization, he experienced decreased perfusion and absence of pulse in his right LE. Because of persistent ischemia, he underwent a side-arm graft anastomosis to the contralateral FA, as described earlier. The right FA cannula was removed, and distal perfusion normalized. The FA graft provided excellent flow to his upper body, as demonstrated by normal radial artery and cerebral near-infrared spectroscopy (cNIRS) saturations. He had no further ischemic or bleeding complications as result of either cannulation site, and weaning from ECMO on day 8 was successful. A 15-year-old boy presented with cardiovascular collapse secondary to viral myocarditis. He was emergently given VA-ECMO by percutaneous cannulation with 17F right FA and 21F right femoral venous (FV) cannulas. After stabilization, he experienced decreased perfusion and absence of pulse in his right LE. Because of persistent ischemia, he underwent a side-arm graft anastomosis to the contralateral FA, as described earlier. The right FA cannula was removed, and distal perfusion normalized. The FA graft provided excellent flow to his upper body, as demonstrated by normal radial artery and cerebral near-infrared spectroscopy (cNIRS) saturations. He had no further ischemic or bleeding complications as result of either cannulation site, and weaning from ECMO on day 8 was successful. Patient 2A 22-year-old man with congenital aortic stenosis was admitted with worsening stenosis and decompensated heart failure. His condition became unstable, with frequent episodes of syncope and coronary ischemia, requiring VA-ECMO. Percutaneous cannulation was performed with 19F right FA and 21F right FV cannulas with the patient under moderate sedation. After stabilization, he underwent general anesthesia for revision of the arterial cannulation to a side-arm graft; the initial arterial cannula was removed. The next day a large hematoma was noted at the cannulation site; bedside exploration revealed diffuse oozing at the graft anastomosis suture line. Bleeding was controlled with pledgeted suture and a bovine pericardial patch to tamponade further oozing. He had no further bleeding complications and maintained excellent distal lower extremity perfusion. His radial artery saturations and cNIRS remained normal during ECMO support. On ECMO day 3, he underwent balloon dilatation of his aortic valve with improvement of his ventricular function, enabling successful weaning from ECMO the next day. A 22-year-old man with congenital aortic stenosis was admitted with worsening stenosis and decompensated heart failure. His condition became unstable, with frequent episodes of syncope and coronary ischemia, requiring VA-ECMO. Percutaneous cannulation was performed with 19F right FA and 21F right FV cannulas with the patient under moderate sedation. After stabilization, he underwent general anesthesia for revision of the arterial cannulation to a side-arm graft; the initial arterial cannula was removed. The next day a large hematoma was noted at the cannulation site; bedside exploration revealed diffuse oozing at the graft anastomosis suture line. Bleeding was controlled with pledgeted suture and a bovine pericardial patch to tamponade further oozing. He had no further bleeding complications and maintained excellent distal lower extremity perfusion. His radial artery saturations and cNIRS remained normal during ECMO support. On ECMO day 3, he underwent balloon dilatation of his aortic valve with improvement of his ventricular function, enabling successful weaning from ECMO the next day. Patient 3A 43-year-old man with tetralogy of Fallot presented for tricuspid valve replacement. He underwent cannulation for cardiopulmonary bypass (CPB) with a left FA cannula. A long intraoperative course was complicated by severe bleeding. After weaning from CPB, he experienced low cardiac output and rapidly progressive lactic acidosis, requiring VA-ECMO support by a side-arm graft attached to the left FA and a 25F FV cannula. Severe postoperative bleeding precluded the initial use of heparin; the cannulation site was packed with sponges, and the skin temporarily closed with a bovine pericardial patch. He experienced no further bleeding complications and maintained normal LE perfusion. Weaning from ECMO was successful day three. A 43-year-old man with tetralogy of Fallot presented for tricuspid valve replacement. He underwent cannulation for cardiopulmonary bypass (CPB) with a left FA cannula. A long intraoperative course was complicated by severe bleeding. After weaning from CPB, he experienced low cardiac output and rapidly progressive lactic acidosis, requiring VA-ECMO support by a side-arm graft attached to the left FA and a 25F FV cannula. Severe postoperative bleeding precluded the initial use of heparin; the cannulation site was packed with sponges, and the skin temporarily closed with a bovine pericardial patch. He experienced no further bleeding complications and maintained normal LE perfusion. Weaning from ECMO was successful day three. CommentThe femoral vessels are frequently cannulated for VA-ECMO because they offer relatively easy access to the central circulation and are associated with decreased bleeding and neurologic complications. Because the arterial cannula may approach the diameter of the FA, distal leg perfusion can become compromised. The incidence of LE ischemia ranges from 10% to 50% in patients with FA cannulation [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar].The procedure in this report was adapted from the axillary artery CPB cannulation technique used by our cardiovascular surgeons. The success of this technique in rescuing our first patient from LE ischemia led us to explore it as our primary method of FA ECMO cannulation. We believe that ischemia related to cannula obstruction could be eliminated with this side-arm graft technique. All 3 patients demonstrated excellent LE perfusion (warm and pink), with easily palpable pulses once contractility returned. Historically, our patients whose FAs were directly cannulated had a temperature difference between the feet and rarely had palpable LE pulses.Other techniques are reported to decrease the risk of distal leg ischemia seen in femoral VA-ECMO; most involve variations of DPCs that can be percutaneously or surgically placed distal to the ECMO cannulation site [3Russo C.F. Cannata A. Vitali E. Lanfranconi M. Prevention of limb ischemia and edema during peripheral venoarterial extracorporeal membrane oxygenation in adults.J Card Surg. 2009; 24: 185-187Crossref PubMed Scopus (32) Google Scholar, 4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 5Greason K.L. Hemp J.R. Maxwell J.M. Fetter J.E. Moreno-Cabral R.J. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation.Ann Thorac Surg. 1995; 60: 209-210PubMed Scopus (63) Google Scholar, 6Kasirajan V. Simmons I. King J. Shumaker M.D. DeAnda A. Higgins R.S. Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation.Perfusion. 2002; 17: 427-428Crossref PubMed Scopus (26) Google Scholar]. Investigators have still reported ischemia and tissue damage with their use, side effects of their placement, or both [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. Our side-arm graft technique avoids intraluminal cannulas entirely, which should nearly eliminate the occurrence of LE ischemia in addition to allowing antegrade and retrograde blood flow. All 3 patients had normal retrograde (upper body) oxygen delivery as measured by cNIRS monitoring and measurements of radial arterial and superior vena cava venous saturation.The anastomosis of prosthetic vascular grafts to the FA has previously been described for CPB [7Vander Salm T.J. Prevention of lower extremity ischemia during cardiopulmonary bypass via femoral cannulation.Ann Thorac Surg. 1997; 63: 251-252Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar] and ECMO support [8Doll N. Kiaii B. Borger M. et al.Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.Ann Thorac Surg. 2004; 77 (discussion 157): 151-157Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar]. Although they did not describe it in detail, Doll and colleagues [8Doll N. Kiaii B. Borger M. et al.Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.Ann Thorac Surg. 2004; 77 (discussion 157): 151-157Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar] mentioned performing anastomosis of a 6-mm Hemashield prosthesis to the FA in a review of their vast ECMO experience. They observed decreased ischemia after the change from percutaneous cannulation, but it is not clear how many patients underwent cannulation in this manner and whether increased bleeding or other complications resulted.One advantage of femoral cannulation is that the vessels are easily cannulated percutaneously, offering the potential for emergent access. Our technique requires cutdown exposure and arteriotomy of the FA, increasing cannulation time and bleeding risks in comparison with the percutaneous technique. The second patient highlighted this limitation, given that he had significant bleeding at the anastomosis site, requiring reexploration. The potential for increased risk of bleeding and infection (foreign material) makes it necessary to delineate patient populations that may benefit most from this cannulation technique. Patients with smaller vessels likely to be occluded by arterial cannulas [4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar] (children, thin adults, peripheral artery disease [2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]), patients in whom ischemia develops after percutaneous cannulation, or patients who undergo cannulation in the operating room with vessels already exposed for CPB (similar to our third patient) all may be attractive candidates for this approach.In conclusion, our variation of a side-arm graft to establish FA access is effective in reversing or preventing distal LE ischemia, or both, associated with femoral VA-ECMO. Prospective studies are necessary to determine whether this technique has a sufficiently favorable side effect profile compared with percutaneous cannulation to warrant its prophylactic use in all patients. The femoral vessels are frequently cannulated for VA-ECMO because they offer relatively easy access to the central circulation and are associated with decreased bleeding and neurologic complications. Because the arterial cannula may approach the diameter of the FA, distal leg perfusion can become compromised. The incidence of LE ischemia ranges from 10% to 50% in patients with FA cannulation [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]. The procedure in this report was adapted from the axillary artery CPB cannulation technique used by our cardiovascular surgeons. The success of this technique in rescuing our first patient from LE ischemia led us to explore it as our primary method of FA ECMO cannulation. We believe that ischemia related to cannula obstruction could be eliminated with this side-arm graft technique. All 3 patients demonstrated excellent LE perfusion (warm and pink), with easily palpable pulses once contractility returned. Historically, our patients whose FAs were directly cannulated had a temperature difference between the feet and rarely had palpable LE pulses. Other techniques are reported to decrease the risk of distal leg ischemia seen in femoral VA-ECMO; most involve variations of DPCs that can be percutaneously or surgically placed distal to the ECMO cannulation site [3Russo C.F. Cannata A. Vitali E. Lanfranconi M. Prevention of limb ischemia and edema during peripheral venoarterial extracorporeal membrane oxygenation in adults.J Card Surg. 2009; 24: 185-187Crossref PubMed Scopus (32) Google Scholar, 4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 5Greason K.L. Hemp J.R. Maxwell J.M. Fetter J.E. Moreno-Cabral R.J. Prevention of distal limb ischemia during cardiopulmonary support via femoral cannulation.Ann Thorac Surg. 1995; 60: 209-210PubMed Scopus (63) Google Scholar, 6Kasirajan V. Simmons I. King J. Shumaker M.D. DeAnda A. Higgins R.S. Technique to prevent limb ischemia during peripheral cannulation for extracorporeal membrane oxygenation.Perfusion. 2002; 17: 427-428Crossref PubMed Scopus (26) Google Scholar]. Investigators have still reported ischemia and tissue damage with their use, side effects of their placement, or both [1Gander J.W. Fisher J.C. Reichstein A.R. et al.Limb ischemia after common femoral artery cannulation for venoarterial extracorporeal membrane oxygenation: an unresolved problem.J Pediatr Surg. 2010; 45: 2136-2140Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. Our side-arm graft technique avoids intraluminal cannulas entirely, which should nearly eliminate the occurrence of LE ischemia in addition to allowing antegrade and retrograde blood flow. All 3 patients had normal retrograde (upper body) oxygen delivery as measured by cNIRS monitoring and measurements of radial arterial and superior vena cava venous saturation. The anastomosis of prosthetic vascular grafts to the FA has previously been described for CPB [7Vander Salm T.J. Prevention of lower extremity ischemia during cardiopulmonary bypass via femoral cannulation.Ann Thorac Surg. 1997; 63: 251-252Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar] and ECMO support [8Doll N. Kiaii B. Borger M. et al.Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.Ann Thorac Surg. 2004; 77 (discussion 157): 151-157Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar]. Although they did not describe it in detail, Doll and colleagues [8Doll N. Kiaii B. Borger M. et al.Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock.Ann Thorac Surg. 2004; 77 (discussion 157): 151-157Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar] mentioned performing anastomosis of a 6-mm Hemashield prosthesis to the FA in a review of their vast ECMO experience. They observed decreased ischemia after the change from percutaneous cannulation, but it is not clear how many patients underwent cannulation in this manner and whether increased bleeding or other complications resulted. One advantage of femoral cannulation is that the vessels are easily cannulated percutaneously, offering the potential for emergent access. Our technique requires cutdown exposure and arteriotomy of the FA, increasing cannulation time and bleeding risks in comparison with the percutaneous technique. The second patient highlighted this limitation, given that he had significant bleeding at the anastomosis site, requiring reexploration. The potential for increased risk of bleeding and infection (foreign material) makes it necessary to delineate patient populations that may benefit most from this cannulation technique. Patients with smaller vessels likely to be occluded by arterial cannulas [4Haley M.J. Fisher J.C. Ruiz-Elizalde A.R. Stolar C.J. Morrissehy N.J. Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child.J Pediatr Surg. 2009; 44: 437-440Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar] (children, thin adults, peripheral artery disease [2Bisdas T. Beutel G. Warnecke G. et al.Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support.Ann Thorac Surg. 2011; 92: 626-631Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar]), patients in whom ischemia develops after percutaneous cannulation, or patients who undergo cannulation in the operating room with vessels already exposed for CPB (similar to our third patient) all may be attractive candidates for this approach. In conclusion, our variation of a side-arm graft to establish FA access is effective in reversing or preventing distal LE ischemia, or both, associated with femoral VA-ECMO. Prospective studies are necessary to determine whether this technique has a sufficiently favorable side effect profile compared with percutaneous cannulation to warrant its prophylactic use in all patients.