Risk factors for cannula-associated arterial thrombosis following extracorporeal membrane oxygenation support: a retrospective study

Abstract

Background: Hemostatic dysfunction during extracorporeal membrane oxygenation (ECMO) due to blood-circuit interaction and the consequences of shear stress imposed by flow rates lead to rapid coagulation cascade and thrombus formation in the ECMO system and blood vessels. We aimed to identify the incidence and risk factors for cannula-associated arterial thrombosis (CaAT) post-decannulation.

Methods: A retrospective study of patients undergoing arterial cannula removal following ECMO was performed. We evaluated the incidence of CaAT and compared the characteristics, ECMO machine parameters, cannula sizes, number of blood products transfused during ECMO, and daily hemostasis parameters in patients with and without CaAT. Multivariate analysis identified the risk factors for CaAT.

Results: Forty-seven patients requiring venoarterial ECMO (VA-ECMO) or hybrid methods were recruited for thrombosis screening. The median Sequential Organ Failure Assessment score was 11 (interquartile range, 8-13). CaAT occurred in 29 patients (61.7%), with thrombosis in the superficial femoral artery accounting for 51.7% of cases. The rate of limb ischemia complications in the CaAT group was 17.2%. Multivariate analysis determined that the ECMO flow rate-body surface area (BSA) ratio (100 ml/min/m2) was an independent factor for CaAT, with an odds ratio of 0.79 (95% confidence interval, 0.66-0.95; P=0.014).

Conclusions: We found that the incidence of CaAT was 61.7% following successful decannulation from VA-ECMO or hybrid modes, and the ECMO flow rate-BSA ratio was an independent risk factor for CaAT. We suggest screening for arterial thrombosis following VA-ECMO, and further research is needed to determine the risks and benefits of such screening.

Keywords: blood flow; cannula-associated thrombosis; extracorporeal membrane oxygenation.

Figure 1.

Position of arterial thrombus formation in the low-flow space. Created with BioRender.com.

Figure 2.

Flowchart of patient inclusion. ECMO: extracorporeal membrane oxygenation; PE: pulmonary embolism; VA: arteriovenous; CaAT: cannula-associated arterial thrombosis.

Figure 3.

The distribution of cannula-associated arterial thrombosis.

Figure 4.

Detection of thrombus on bedside Doppler ultrasound on a 42-year-old male patient after supported extracorporeal membrane oxygenation due to acute myocarditis. (A) The transverse view depicts the color Doppler spectrum in the femoral vein. (B) The longitudinal view revealed nearly complete occlusion of the common femoral artery and superficial femoral artery and the absence of arterial flow by pulsed Doppler, indicating cannula-associated arterial thrombus (red arrow).