Can Extracorporeal Membrane Oxygenation (ECMO) cause extremity necrosis?

From the Guidelines

Yes, ECMO can cause extremity necrosis, as highlighted by the risks of significant complications, including limb ischemia, associated with its use 1. This serious complication typically occurs due to vascular complications associated with the large-bore cannulas used for ECMO, particularly in venoarterial (VA) ECMO. Extremity necrosis can develop from limb ischemia when arterial blood flow is compromised, either from the cannula itself obstructing flow, thromboembolism, or compartment syndrome. Some key points to consider about ECMO and extremity necrosis include:

• The femoral vessels are common access sites, putting the lower extremities at particular risk.
• Prevention strategies include using distal perfusion catheters (which provide blood flow to the limb beyond the cannulation site), regular neurovascular checks of the affected extremity, and monitoring for signs of ischemia such as decreased pulses, skin mottling, temperature changes, or pain.
• Early detection is crucial, as prolonged ischemia can lead to irreversible tissue damage requiring amputation.
• Treatment may involve repositioning the cannula, adding a distal perfusion catheter if not already present, or surgical intervention in severe cases, as noted in the management of patients with cardiac arrest or life-threatening toxicity due to poisoning 1. The risk of this complication underscores the importance of careful patient selection and vigilant monitoring during ECMO therapy, considering the potential benefits and risks, such as those outlined in the 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning 1.

From the Research

ECMO and Extremity Necrosis

• Extremity necrosis is a potential complication of Extracorporeal Membrane Oxygenation (ECMO) therapy, particularly in patients undergoing veno-arterial ECMO [(2,3)].
• The risk of limb ischemia and necrosis is associated with the cannulation site and technique, with femoral and axillary cannulation being more commonly associated with these complications [(2,3)].
• Studies have reported that limb ischemia occurs in approximately 11-20% of patients undergoing VA-ECMO [(2,3)].
• The use of distal perfusion cannula (DPC) and ultrasound-guided cannulation may help reduce the risk of limb ischemia and bleeding 3.
• Femoral neuropathy is another potential complication of ECMO therapy, which can result from nerve compression caused by cannula compression and deep vein thrombosis 4.
• Computational fluid dynamics studies have investigated the effects of lower-extremity cannulation on intra-arterial flow characteristics, oxygen content, and thrombosis risk, highlighting the importance of optimizing cannulation techniques to minimize complications 5.

Risk Factors and Prevention

• Risk factors for extremity necrosis and other complications include older age, worse baseline heart failure, and cannulation site bleeding 3.
• Strategies to prevent these complications include careful selection of cannulation sites, use of ultrasound-guided cannulation, and monitoring for signs of limb ischemia and neuropathy [(2,3,4)].
• Further research is needed to optimize ECMO therapy and minimize the risk of complications, particularly in critically ill patients [(6,5)].