Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study

Abstract

Purpose: Femoral artery surgical cannulation is the reference for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults. However, the less invasive percutaneous approach has been associated with lower rates of complications. This retrospective study compared complication rates and overall survival in a large series of patients who received surgical or percutaneous peripheral VA-ECMO. Methods: All consecutive patients implanted with VA-ECMO between January 2015 and December 2017 in a high ECMO-volume university hospital were included. Surgical cannulation was the only approach until late 2016 after which the percutaneous approach became the first line strategy. Propensity score framework analyzes were used to compare outcomes of percutaneous and surgical groups while controlling for confounders. Results: Among the 814 patients who received VA-ECMO (485 surgical and 329 percutaneous), propensity-score matching selected 266 unique pairs of patients with similar characteristics. Percutaneous cannulation was associated with fewer local infections (16.5% versus 27.8%, p = 0.001), similar rates of limb ischemia (8.6% versus 12.4%, p = 0.347) and sensory-motor complications (2.6% versus 2.3%, p = 0.779) and improved 30-day survival (63.8% versus 56.3%, p = 0.034). However, more vascular complications following decannulation (14.7% versus 3.4%, p < 0.001), mainly persistent bleeding requiring surgical revision (9.4% vs. 1.5%, p < 0.001), occurred after percutaneous cannulation. Conclusions: Compared to the surgical approach, percutaneous cannulation for peripheral VA-ECMO was associated with fewer local infections, similar rates of ischemia and sensory-motor complications and improved 30-day survival. The higher rate of vascular complications following decannulation suggests that improvements in cannula removal techniques are needed to further improve patients’ outcomes after percutaneous cannulation.