Comparing the outcomes of bedside percutaneous VA-ECMO decannulation by ProGlide and Manta in a high-ECMO-volume center in Hong Kong.

BACKGROUND: The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation with different percutaneous closure devices has been increasing. At our center, ProGlide devices have been used since November 2018, and Manta devices became an alternative since March 2020. This study aimed to compare the success and complication rates and the clinical outcomes of ProGlide and Manta devices for VA-ECMO decannulation after arteriotomy wound closure. METHODS: We retrospectively reviewed the results of bedside VA-ECMO decannulation between November 2018 and June 2021. Patients with VA-ECMO who could be bridged to recovery were recruited and divided into the ProGlide or Manta group based on the closure device used. Procedure time, amount of blood loss, amount of blood products transfused, and use of vasoactive medications during the procedure were documented. Clinical examination and Doppler ultrasound were performed to detect any complications. RESULTS: After the closure technique, ProGlide was used in 44 patients and Manta was used in 13. There was no significant difference in the success rate between the ProGlide and Manta groups (86.4% vs. 100%). Amount of blood loss was greater in the ProGlide group than in the Manta group (290 [100-400] ml vs. 50 [50-100] ml), and more patients in the ProGlide group required an increased dose of inotropes during the procedure (59.1% vs. 15.4%), but the transfusion requirement was similar between the two groups. CONCLUSIONS: The success rate of hemostasis using arteriotomy wound closure during VA-ECMO decannulation was similar between the two devices.

Enhanced vascular assessment by ultrasound using microbubble contrast after percutaneous decannulation of peripheral veno-arterial extracorporeal membrane oxygenation.

Termination of peripheral veno-arterial extracorporeal membrane oxygenation support by managing the arteriotomy wound using a percutaneous closure device was reported successful and effective. However, careful assessment by clinical examination and also ultrasound Doppler assessment of the lower limb vasculature after closure is of paramount importance. Complications including pseudoaneurysm, arterial stenosis, and acute thrombosis are not uncommon. In this case report, commercial microbubbles were used as ultrasound contrast to enhance the image quality for better vascular ultrasound and Doppler assessment after veno-arterial extracorporeal membrane oxygenation percutaneous decannulation. A peudoaneurysm was revealed after microbubble injection, which would otherwise be missed.

One-year experience of bedside percutaneous VA-ECMO decannulation in a high-ECMO-volume center in Hong Kong.

BACKGROUND: When veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support can be terminated, open repair of arteriotomy wounds in operating theaters is the standard of practice. Comparable outcomes by percutaneous decannulation using different closure devices have been reported. However, transport of the critically- ill, man-power and timeslots of operating theaters could be saved if decannulation was performed at bedside. METHOD: Bedside percutaneous arteriotomy wound closure became our default method of decannulation since November 2018. We reviewed our 1-year data to evaluate if such practice could be safely adopted in a local high-ECMO-volume center. RESULTS: Between November 2018 and October 2019, 25 patients had their VA-ECMO terminated at the bedside. Twenty-one patients (84%) had successful decannulation. For those who failed, emergency open repair resulted in no additional complications. Two ProGlide devices were used in 15 (71.4%) patients and three were used in 6 (28.6%) patients. The procedure time was 27 (15-45) min. The median blood loss was 300 mL (250-400). Minor complications were found in 4 (19.1%) patients, including two arterial clot formation, one pseudoaneurysm and one wound infection. There were no other major complications. CONCLUSION: Our 1-year experience showed that percutaneous bedside VA-ECMO decannulation was feasible to commence in a local large-ECMO-volume center.

Simulation training on bedside veno-arterial extracorporeal membrane oxygenation decannulation.

Veno-arterial extracorporeal membrane oxygenation is a form of mechanical circulatory support for patients with refractory decompensated heart failure. Blood is drawn from a large vein and pumped back to a large artery, usually a femoral artery through large bore catheters. When the heart recovers, the extracorporeal membrane oxygenation support can be terminated and the catheters are decannulated. The bleeding at the venous side can be controlled by prolonged compression; however, the arteriotomy wound needs to be repaired. Conventionally, the arteriotomy wounds require open vascular repair in the operating theater. The novel application of percutaneous vascular closure devices, which have been commonly used in vascular operations and percutaneous structural heart interventions, could be applied for closure of arteriotomy wounds at the bedside after extracorporeal membrane oxygenation support. The post-close ProGlide (Abbott Vascular) technique was shown to be safe and could potentially save time and manpower. The wounds are much smaller as compared with the conventional open repair and potentially, the chance of wound infection can be reduced. However, the success of percutaneous bedside closure requires careful prior planning and technique training. Backup plans with vascular surgeons' standby are essential in case of failure of closure. Staffs in the extracorporeal membrane oxygenation centers need to be familiar with the preparation, the procedure as well as the device application technique for successful percutaneous closure. The long learning curve and the limited case load mean that such skills are best trained by simulation scenarios. This article described how this new technique and the team logistics can be trained by simulation.