(1528) Axillary-Femoral Graft Cannulation for Resuscitative ECMO

Introduction: Peripheral resuscitative VA ECMO, also known as extracorporeal cardiopulmonary resuscitation (ECPR), is emerging as not only a viable, but possibly superior resuscitation strategy compared to standard resuscitation, in refractory cardiac arrest. However, presumed relative contraindications such as severe peripheral artery disease have classically restricted candidacy for ECPR, despite the possibility of meaningful survival.

Description: A 62-year-old male with a known history of severe multivessel coronary artery disease, presented to the ED with refractory ventricular fibrillation. Despite 45 minutes of CPR, the patient demonstrated signs of life, and the decision was made to bridge to definitive coronary revascularization with ECPR. Chart review prior to cannulation noted history of chronic total occlusion of the infrarenal aorta, status post right axillary-femoral and femoral-femoral bypass grafts.

After uneventful right femoral vein cannulation, the right common femoral artery was accessed for cannulation of the right axillary-femoral graft with a 17 French arterial cannula. The return cannula was carefully positioned to allow systemic perfusion via the right axillary-femoral bypass graft in addition to the left lower extremity via the femoral-femoral bypass graft. A 5 French distal perfusion cannula (DPC) was introduced to perfuse the right lower extremity. Sustained return of spontaneous circulation was achieved via defibrillation shortly after cannulation, after greater than 70 minutes of CPR. Computed tomography confirmed return cannula placement into the distal axillary-femoral bypass graft.

The patient was extubated on hospital day 1, and underwent two-vessel coronary artery bypass on hospital day 2. After decannulation on hospital day 7 he underwent right superficial femoral artery embolectomy and primary repair of the access sites. There were no major vascular or graft complications. He was discharged home on hospital day 15 with a 40-45% LVEF, and was able to return to work within 6 months of discharge.

Discussion: We present a case of successful resuscitative ECMO cannulation for ECPR in a patient with known aortoiliac occlusive disease. Patients previously thought to have contraindications to ECMO cannulation can indeed be potentially good candidates for ECPR.