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: Chiarini Giovanni , Mariani Silvia , Schaefer Anne-Kristin , van Bussel Bas C. T. , Di Mauro Michele , Wiedemann Dominik , Saeed Diyar , Pozzi Matteo , Botta Luca , Boeken Udo , Samalavicius Robertas , Bounader Karl , Hou Xiaotong , Bunge Jeroen J. H. , Buscher Hergen , Salazar Leonardo , Meyns Bart , Herr Daniel , Matteucci Sacha , Sponga Sandro , Ramanathan Kollengode , Russo Claudio , Formica Francesco , Sakiyalak Pranya , Fiore Antonio , Camboni Daniele , Raffa Giuseppe Maria , Diaz Rodrigo , Wang I-wen , Jung Jae-Seung , Belohlavek Jan , Pellegrino Vin , Bianchi Giacomo , Pettinari Matteo , Barbone Alessandro , Garcia José P. , Shekar Kiran , Whitman Glenn J. R. , Lorusso Roberto ,   on behalf of the PELS Investigators, Heuts Samuel , Conci Luca , Khalil Jawad , Lehmann Sven , Obadia Jean-Francois , Loforte Antonio , Pacini Davide , Kalampokas Nikolaos , Jankuviene Agne , Bounader Karl , Flecher Erwan , Dos Reis Miranda Dinis , Sriranjan Kogulan , Mazzeffi Michael A. , Di Eusanio Marco , Vendramin Igor , MacLaren Graeme , Sorokin Vitaly , Costetti Alessandro , Schmid Chistof , Castillo Roberto , Grus Tomas , Solinas Marco 
Published: August 2024

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.

Graphical abstract