Early vascular complications after percutaneous cannulation for extracorporeal membrane oxygenation for cardiac assist.

BACKGROUND: Extracorporeal membrane oxygenation (VA ECMO) demonstrated an advantage in survival and neurological outcome in patients with cardiogenic shock and, in selected population, in victims of refractory cardiac arrest. The incidence of vascular complications ranges in recent series from 10 to 70% including both early and late complications. The aim of the present study was to determine the incidence of early vascular complications and the effectiveness of the prevention of limb ischemia by the insertion of a catheter for distal perfusion. METHODS: Data from our registry of 100 patients treated with VA ECMO implanted via percutaneous femoral approach for cardiogenic shock or refractory cardiac arrest were analyzed. If the leg perfusion was inadequate, an additional 7-9 Fr percutaneous catheter distal to the ECMO arterial cannula was placed into the femoral artery to prevent limb ischemia. RESULTS: Thirty-five patients had early vascular complications. Thirty patients with early ischemia were cannulated with a small reperfusion cannula to obtain antegrade perfusion of the limb. Twenty-six had an effective reperfusion. Seven patients developed a compartment syndrome of the leg requiring urgent fasciotomy that led to clinical improvement and recovery in five, while the other two patients progressed to irreversible ischemia requiring amputation of the limb. CONCLUSION: The majority of ischemic episodes were resolved with the insertion of a distal perfusion catheter. We did not observe any mortal vascular complication, nor any of the observed complications was related to increased mortality.

What have we learned from the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study?

Carotid artery stenting (CAS) is used widely to treat carotid lesions. Indication to CAS is mostly based, both in trial and in clinical practice, on the percentage of stenosis and the presence or absence of preprocedural neurologic symptoms, whereas the features of the plaque are somehow disregarded and ignored. The most severe complication of CAS is stroke, related to cerebral embolization from carotid plaque. Several studies showed that echolucent plaques generate a higher number of embolic particles following carotid stenting. Echolucency can be measured using the gray scale median, which is an objective and quantitative computer-assisted grading of the echogenicity of carotid plaques. As previously demonstrated in the ICAROS study, carotid plaque echolucency is an independent risk factor for stroke in carotid stenting. Carotid plaque echolucency is one of the parameters that should be mandatory to be considered for indication to treatment.