Venous or arterial thromboses after venoarterial extracorporeal membrane oxygenation support: Frequency and risk factors

doi:10.1016/j.healun.2020.12.007

The Journal of Heart and Lung Transplantation

Volume 40, Issue 4, April 2021, Pages 307-315

https://doi.org/10.1016/j.healun.2020.12.007 Get rights and content

BACKGROUND

Although venous thrombosis after venovenous–extracorporeal membrane oxygenation (ECMO) is well described, vascular complications occurring after venoarterial ECMO (VA-ECMO) removal have not yet been thoroughly described. Our aim was to evaluate the frequency of vascular (arterial and venous) complications after VA-ECMO removal and try to identify the risk factors associated with them.

METHODS

Retrospective analysis of data prospectively collected in 2 intensive care units was performed. Consecutive patients successfully weaned off VA-ECMO during year 1 were screened for cannula-associated deep vein thrombosis (CaDVT) or arterial complications (arterial thrombosis/stenosis) using Doppler ultrasonography.

RESULTS

From November 2018 to November 2019, a total of 107 patients with a median (interquartile range [IQR]) age of 54 (42–63) years and a median (IQR) ECMO support duration of 8 (2–5) days were successfully weaned off VA-ECMO and included. CaDVT occurred in 44 patients (41%), and arterial complications occurred in 15 (14%) (9 acute leg ischemia, 1 arteriovenous femoral fistula, and 5 late femoral stenosis). Multivariable analysis retained longer duration of ECMO support (odds ratio [OR]: 1.12 per day; 95% CI: 1.02–1.22) and infection occurring on ECMO (OR: 3.03; 95% CI: 1.14–8.03) as independent risk factors for CaDVT, whereas older age (OR: 0.97 per year; 95% CI: 0.94–0.99) and previous anti-coagulation use (OR: 0.21; 95% CI: 0.06–0.68) were protective factors for CaDVT. No risk factors for arterial complications were identified.

CONCLUSIONS

In patients requiring VA-ECMO support, vascular complications occurred frequently after its removal, especially CaDVT. Arterial complications, either early leg ischemia or late arterial stenosis, were observed less often. Strategies aimed at preventing CaDVT after VA-ECMO remain to be determined.

Section snippets

Patients

All consecutive patients who received VA-ECMO and were successfully weaned off it in 2 ICUs between November 2018 and November 2019 were included. Patients who had <48 hours of extracorporeal membrane oxygenation (ECMO) run, died on ECMO, or were not screened for cannula-related thrombosis were excluded. All the following information was collected prospectively: ICU admission Simplified Acute Physiology Score II and Sequential Organ-Failure Assessment score, local infectious complications

Patient characteristics

Between November 2018 and November 2019, a total of 107 patients were successfully weaned off ECMO, and all were included in the study. Their median age was 54 (42–63) years, and the median time on ECMO support was 8 (2–15) days. The main indications for ECMO were acute on chronic cardiac failure (35.5%) and post-cardiotomy care (31.8%). VAV-ECMO hook up was used for 5 patients. Their baseline characteristics, course on ECMO, and outcomes are reported in Table 1.

CaDVT and arterial complications

Among the 107 patients, 44 (41%)

Discussion

The results of this study showed that arterial thrombosis and CaDVT were frequent in VA-ECMO–treated patients, with the latter occurring in 41% of patients and being more frequent than the former. In addition, several risk factors for developing CaDVT in this population were identified, namely infection on ECMO support and longer duration of ECMO support, whereas older age and anti-coagulant therapy before ECMO support were protective factors. To the best of our knowledge, vascular

Conclusions

In conclusion, vascular complications after VA-ECMO removal are frequent. CaDVT was the most frequent and should be actively sought in every patient after VA-ECMO explantation, especially in patients with prolonged ECMO runs, or when an on-ECMO infection occurs. Arterial complications were less frequent and could occur early after ECMO withdrawal (acute ischemia) or later (arterial stenosis). Further studies are needed to evaluate the precise duration of anti-coagulation in patients with CaDVT.

Disclosure statement

C.E.L. reports personal fees from Merck Sharp and Dohme, Thermo Fischer Brahms, Biomérieux, Carmat, Bayer Healthcare, and Aerogen and grants from Bayer Healthcare, outside the scope of the submitted work. M.S. reports lecture fees from Maquet, Getinge, and Fresenius, outside the scope of the submitted work. The remaining authors have no conflicts of interest to disclose.

The authors thank Janet Jacobson for her help during the preparation of the manuscript.

Support for this study was provided

Author contributions

All authors participated in data collection and final manuscript preparation and agreed on the latest manuscript.

Concept and design: F.B., C.E.L.

Acquisition, analysis, or interpretation of data: F.B., C.E.L.

Drafting of the manuscript: F.B., C.E.L.

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Drainage cannulae extract blood from a patient during venoarterial extracorporeal membrane oxygenation (VA ECMO), a treatment that temporarily supports patients undergoing severe heart and/or lung dysfunction. Currently, the two most commonly used multi-stage drainage cannulae are manufactured by Maquet and Bio-Medicus, but their designs vary in many aspects which impacts the generated flow dynamics. Therefore, this study aimed to use computational fluid dynamics (CFD) to explore the flow characteristics of the aforementioned cannulae and their impact on complications such as thrombosis.
The Maquet and Bio-Medicus cannulae were 3D modelled within a patient-specific geometry of the venous vasculature taken from a computed tomography scan of a patient undergoing VA ECMO. A drainage flow rate of 4 L/min was assigned to each cannula. Lastly, a stress blended eddy simulation turbulence model was employed to resolve bulk flow turbulence.
The proximal row of side holes in both cannulae generated high intensity counter-rotating vortices, thus generating supraphysiological shear. These proximal rows were also responsible for the majority of flow extraction in both cannulae ( $>$ 1.6 L/min). Despite identical simulation settings, each cannulae had differing impacts on global flow dynamics. For instance, the Bio-Medicus model produced a total stagnant blood volume of 25.6 ml, compared to 17.8 ml the Maquet cannula, thereby increasing the risk of thrombosis.
Overall, our results demonstrate that differences in design clearly impact flow dynamics and risk of complications. Therefore, further work in optimizing cannula design may be beneficial to prevent harmful flow characteristics.
Successful treatment of near-fatal pulmonary embolism and cardiac arrest in an adult patient with fulminant psittacosis-induced severe acute respiratory distress syndrome after veno-venous extracorporeal membrane oxygenation rescue: A case report and follow-up
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Veno-venous extracorporeal membrane oxygenation (ECMO) was successfully performed for the rescue of an adult patient with severe acute respiratory distress syndrome (ARDS) induced by fulminant psittacosis, and then a near-fatal pulmonary embolism (PE) and cardiac arrest (CA) of the same patient was cured through catheter-directed thrombolysis.
A 51-year-old female patient was admitted to the hospital on September 10, 2021 due to slurred speech, weakness in lower limbs, dizziness, and nausea. Subsequently, she developed confusion and was transferred to the intensive care unit (ICU), where she received anti-shock, antibiotics, invasive mechanical ventilation (IMV), and veno-venous ECMO due to the diagnosis of severe pneumonia, severe ARDS, and septic shock based on comprehensive physical examination, laboratory tests, and imaging findings. The metagenomic next-gengeration sequencing (m-NGS) in the bronchoalveolar lavage fluid (BALF) suggested that the pathogen was chlamydia psittaci, so the antibiotics were adjusted to doxycycline combined with azithromycin. After withdrawal from ECMO, ultrasound (US) re-examination of the left lower limb revealed inter-muscular vein thrombosis, following which heparin was replaced by subcutaneous injection of 0.4ml enoxaparin sodium twice daily for anti-coagulation therapy. After withdrawal from IMV, the patient suffered sudden CA and successful cardiopulmonary resuscitation (CPR), and emergency pulmonary angiography (PA) was performed to show bilateral main pulmonary artery embolism. After immediate catheter-directed thrombolysis and placement of an inferior vena cava filter, the patient's condition gradually stabilized.
Veno-venous ECMO can be successfully performed as an emergency life-saving treatment for patients with severe ARDS induced by fulminant psittacosis, and during ECMO regular examinations should be conducted to detect and manage thrombosis in time, thereby avoiding the occurrence of near-fatal PE and CA.
Thombosis, major bleeding, and survival in COVID-19 supported by veno-venous extracorporeal membrane oxygenation in the first vs second wave: a multicenter observational study in the United Kingdom
2023, Journal of Thrombosis and Haemostasis
Bleeding and thrombosis are major complications of veno-venous (VV) extracorporeal membrane oxygenation (ECMO).
To assess thrombosis, major bleeding (MB), and 180-day survival in patients supported by VV-ECMO between the first (March 1 to May 31, 2020) and second (June 1, 2020, to June 30, 2021) waves of the COVID-19 pandemic.
An observational study of 309 consecutive patients (aged ≥18years) with severe COVID-19 supported by VV-ECMO was performed in 4 nationally commissioned ECMO centers in the United Kingdom.
Median age was 48 (19-75) years, and 70.6% were male. Probabilities of survival, thrombosis, and MB at 180 days in the overall cohort were 62.5% (193/309), 39.8% (123/309), and 30% (93/309), respectively. In multivariate analysis, an age of >55 years (hazard ratio [HR], 2.29; 95% CI, 1.33-3.93; P = .003) and an elevated creatinine level (HR, 1.91; 95% CI, 1.19-3.08; P = .008) were associated with increased mortality. Correction for duration of VV-ECMO support, arterial thrombosis alone (HR, 3.0; 95% CI, 1.5-5.9; P = .002) or circuit thrombosis alone (HR, 3.9; 95% CI, 2.4-6.3; P < .001) but not venous thrombosis increased mortality. MB during ECMO had a 3-fold risk (95% CI, 2.6-5.8, P < .001) of mortality. The first wave cohort had more males (76.7% vs 64%; P = .014), higher 180-day survival (71.1% vs 53.3%; P = .003), more venous thrombosis alone (46.4% vs 29.2%; P = .02), and lower circuit thrombosis (9.2% vs 28.1%; P < .001). The second wave cohort received more steroids (121/150 [80.6%] vs 86/159 [54.1%]; P < .0001) and tocilizumab (20/150 [13.3%] vs 4/159 [2.5%]; P = .005).
MB and thrombosis are frequent complications in patients on VV-ECMO and significantly increase mortality. Arterial thrombosis alone or circuit thrombosis alone increased mortality, while venous thrombosis alone had no effect. MB during ECMO support increased mortality by 3.9-fold.
The effect of drainage cannula tip position on risk of thrombosis during venoarterial extracorporeal membrane oxygenation
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Venoarterial extracorporeal membrane oxygenation (VA ECMO) is able to support critically ill patients undergoing refractory cardiopulmonary failure. It relies on drainage cannulae to extract venous blood from the patient, but cannula features and tip position may impact flow dynamics and thrombosis risk. Therefore, this study aimed to investigate the effect of tip position of single-stage (SS) and multi-stage (MS) VA ECMO drainage cannulae on the risk of thrombosis.
Computational fluid dynamics was used to model flow dynamics within patient-specific geometry of the venous vasculature. The tip of the SS and MS cannula was placed in the superior vena cava (SVC), SVC-Right atrium (RA) junction, mid-RA, inferior vena cava (IVC)-RA junction, and IVC. The risk of thrombosis was assessed by measuring several factors. Blood residence time was measured via an Eulerian approach through the use of a scalar source term. Regions of stagnant volume were recognised by identifying regions of low fluid velocity and shear rate. Rate of blood washout was calculated by patching the domain with a scalar value and measuring the rate of fluid displacement. Lastly, wall shear stress values were determined to provide a qualitative understanding of potential blood trauma.
Thrombosis risk varied substantially with position changes of the SS cannula, which was less evident with the MS cannula. The SS cannula showed reduced thrombosis risk arising from stagnant regions when placed in the SVC or SVC-RA junction, whereas an MS cannula was predicted to create stagnant regions during all tip positions. When positioned in the IVC-RA junction or IVC, the risk of thrombosis was higher in the SS cannula than in the MS cannula due to both high and low shear flow.
Tip position of the drainage cannula impacts cannula flow dynamics and, subsequently, the risk of thrombosis. The use of MS cannulae can reduce high shear-related thrombosis, but SS cannulae can eliminate stagnant regions when advanced into the SVC. Therefore, the choice of cannula design and tip position should be carefully considered during cannulation.
Venous thromboembolic events in the setting of extracorporeal membrane oxygenation support in adults: A systematic review
2022, Thrombosis Research
Citation Excerpt :
Both mean partial thromboplastin times less than or equal to 50 s and D-dimer levels are correlated with an increased risk of thrombosis [18,22]. Patients on ECMO therapy for prolonged periods of time, advanced age, and those who had developed an infection during treatment are at an increased risk of developing DVT upon weaning [6,12,14,22–24]. Intriguingly, platelet count less than 100 G/L during ECMO was associated with lower the risk of cannula-associated DVT (hazard ratio, 0.98; 95% CI, 0.98–1.00; p = 0.02) [25].
Extracorporeal membrane oxygenation (ECMO) is a form of prolonged mechanical cardiopulmonary supportive therapy implemented for the survival of patients with refractory cardiac and respiratory dysfunction. Venovenous (VV) and venoarterial (VA) ECMO are both used to buy time in severe respiratory failure while VA ECMO also provides hemodynamic support. Unfortunately, the risk of developing circuit or cannula associated and systemic thrombosis in patients supported by ECMO and post circuit decannulation is a devastating complication, although the relationship between venous thromboembolism (VTE) and ECMO use has not been fully established. Due to the lack of knowledge and literature centered on this topic area, currently there are no official guidelines for prompt diagnosis by screening or to optimize prevention and treatment of VTE in this specific population. This review analyzes the relationship between ECMO and subsequent VTE. We also discuss pertinent prophylactic and therapeutic anticoagulation treatments in patients diagnosed with VTE while on ECMO along with the obstacles associated with them.
Risk factors for cannula-associated arterial thrombosis following extracorporeal membrane oxygenation support: a retrospective study
2023, Acute and Critical Care

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Venous or arterial thromboses after venoarterial extracorporeal membrane oxygenation support: Frequency and risk factors

BACKGROUND

METHODS

RESULTS

CONCLUSIONS

Section snippets

Patients

Patient characteristics

CaDVT and arterial complications

Discussion

Conclusions

Disclosure statement

Author contributions

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Blood

. Chest

Chest

Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence

Curr Opin Crit Care

Current understanding of how extracorporeal membrane oxygenators activate haemostasis and other blood components

Front Med (Lausanne)

Prevalence of deep venous thrombosis among patients in medical intensive care

JAMA

Brain injury during venovenous extracorporeal membrane oxygenation

Intensive Care Med

Runtime and aPTT predict venous thrombosis and thromboembolism in patients on extracorporeal membrane oxygenation: a retrospective analysis

Ann Intensive Care