Observational Study

. 2024 Aug 7;28(1):265.

doi: 10.1186/s13054-024-05047-2.

Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study

Giovanni Chiarini^#^{1

2}, Silvia Mariani^#^{3

4}, Anne-Kristin Schaefer⁵, Bas C T van Bussel⁶, Michele Di Mauro³, Dominik Wiedemann^{5

7}, Diyar Saeed⁸, Matteo Pozzi⁹, Luca Botta¹⁰, Udo Boeken¹¹, Robertas Samalavicius¹², Karl Bounader¹³, Xiaotong Hou¹⁴, Jeroen J H Bunge¹⁵, Hergen Buscher^{16

17}, Leonardo Salazar¹⁸, Bart Meyns¹⁹, Daniel Herr²⁰, Sacha Matteucci²¹, Sandro Sponga²², Kollengode Ramanathan²³, Claudio Russo²⁴, Francesco Formica^{4

25}, Pranya Sakiyalak²⁶, Antonio Fiore²⁷, Daniele Camboni²⁸, Giuseppe Maria Raffa²⁹, Rodrigo Diaz³⁰, I-Wen Wang³¹, Jae-Seung Jung³², Jan Belohlavek³³, Vin Pellegrino³⁴, Giacomo Bianchi³⁵, Matteo Pettinari³⁶, Alessandro Barbone³⁷, José P Garcia³⁸, Kiran Shekar³⁹, Glenn J R Whitman⁴⁰, Roberto Lorusso³; PELS Investigators

Collaborators, Affiliations

Affiliations

¹ Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands. giovanni.chiarini88@gmail.com.
² Intensive Care Unit, Spedali Civili University Hospital, Brescia, Italy. giovanni.chiarini88@gmail.com.
³ Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands.
⁴ Cardiac Surgery Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
⁵ Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
⁶ Department of Intensive Care Medicine, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
⁷ Department of Cardiac Surgery, Karl Landsteiner University, University Clinic St, Pölten, St. Pölten, Austria.
⁸ Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
⁹ Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France.
¹⁰ Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
¹¹ Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany.
¹² II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania.
¹³ Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France.
¹⁴ Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
¹⁵ Department of Intensive Care Adults and Cardiology, Erasmus MC, Rotterdam, The Netherlands.
¹⁶ Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurs, NSW, Australia.
¹⁷ University of New South Wales, Sydney, Australia.
¹⁸ Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia.
¹⁹ Department of Cardiac Surgery, Department of Cardiovascular Sciences, University of Leuven, Louvain, Belgium.
²⁰ Departments of Medicine and Surgery, University of Maryland, Baltimore, USA.
²¹ SOD Cardiochirurgia Ospedali Riuniti 'Umberto I - Lancisi - Salesi' Università Politecnica delle Marche, Ancona, Italy.
²² Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy.
²³ Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore.
²⁴ Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy.
²⁵ Department of Medicine and Surgery, Cardiac Surgery Unit, University of Parma, University Hospital of Parma, Parma, Italy.
²⁶ Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
²⁷ Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France.
²⁸ Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
²⁹ Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo Per I Trapianti e Terapie Ad Alta Specializzazione), Palermo, Italy.
³⁰ Departamento de Anestesia, ECMO Unit, Clínica Las Condes, Las Condes, Santiago, Chile.
³¹ Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, FL, 33021, USA.
³² Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea.
³³ 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
³⁴ Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia.
³⁵ Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy.
³⁶ Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium.
³⁷ Cardiac Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy.
³⁸ IU Health Advanced Heart and Lung Care, Indiana University Methodist Hospital, Indianapolis, IN, USA.
³⁹ Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.
⁴⁰ Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA.

^# Contributed equally.

PMID: 39113082
PMCID: PMC11304572
DOI: 10.1186/s13054-024-05047-2

Observational Study

Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study

Giovanni Chiarini et al. Crit Care. 2024.

. 2024 Aug 7;28(1):265.

doi: 10.1186/s13054-024-05047-2.

Authors

Affiliations

¹ Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands. giovanni.chiarini88@gmail.com.
² Intensive Care Unit, Spedali Civili University Hospital, Brescia, Italy. giovanni.chiarini88@gmail.com.
³ Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands.
⁴ Cardiac Surgery Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
⁵ Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
⁶ Department of Intensive Care Medicine, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
⁷ Department of Cardiac Surgery, Karl Landsteiner University, University Clinic St, Pölten, St. Pölten, Austria.
⁸ Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
⁹ Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France.
¹⁰ Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
¹¹ Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany.
¹² II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania.
¹³ Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France.
¹⁴ Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
¹⁵ Department of Intensive Care Adults and Cardiology, Erasmus MC, Rotterdam, The Netherlands.
¹⁶ Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurs, NSW, Australia.
¹⁷ University of New South Wales, Sydney, Australia.
¹⁸ Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia.
¹⁹ Department of Cardiac Surgery, Department of Cardiovascular Sciences, University of Leuven, Louvain, Belgium.
²⁰ Departments of Medicine and Surgery, University of Maryland, Baltimore, USA.
²¹ SOD Cardiochirurgia Ospedali Riuniti 'Umberto I - Lancisi - Salesi' Università Politecnica delle Marche, Ancona, Italy.
²² Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy.
²³ Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore.
²⁴ Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy.
²⁵ Department of Medicine and Surgery, Cardiac Surgery Unit, University of Parma, University Hospital of Parma, Parma, Italy.
²⁶ Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
²⁷ Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France.
²⁸ Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
²⁹ Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo Per I Trapianti e Terapie Ad Alta Specializzazione), Palermo, Italy.
³⁰ Departamento de Anestesia, ECMO Unit, Clínica Las Condes, Las Condes, Santiago, Chile.
³¹ Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, FL, 33021, USA.
³² Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea.
³³ 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
³⁴ Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia.
³⁵ Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy.
³⁶ Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium.
³⁷ Cardiac Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy.
³⁸ IU Health Advanced Heart and Lung Care, Indiana University Methodist Hospital, Indianapolis, IN, USA.
³⁹ Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.
⁴⁰ Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA.

^# Contributed equally.

PMID: 39113082
PMCID: PMC11304572
DOI: 10.1186/s13054-024-05047-2

Abstract

Background: Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications.

Methods: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models.

Results: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar.

Conclusions: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.

Keywords: Cardiac arrest; Cardiac surgery; Extracorporeal membrane oxygenation; ICH; Neurologic complications; Stroke.

PubMed Disclaimer

Conflict of interest statement

DW: consultant/proctor for Abbott; scientific advisor for Xenios. RL: consultant for Medtronic, Getinge and LivaNova; Advisory Board Member of Eurosets (honoraria paid as research funding). KR: received honoraria from Baxter and Fresenius Ltd for educational lectures.

Figures

**Fig. 1**
Composite neurologic end-point including stroke, cerebral hemorrhage and brain edema

**Fig. 2**
Overall In-hospital Mortality. ECLS = Extracorporeal Life Support

**Fig. 3**
Kaplan–meier plot of survival in subclavian artery versus femoral artery versus aorta cannulation

See this image and copyright information in PMC

References

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Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study

Collaborators

Affiliations

Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

Figures

References

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MeSH terms

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