Bilateral Femoral Cannulation Is Associated With Reduced Severe Limb Ischemia-Related Complications Compared With Unilateral Femoral Cannulation in Adult Peripheral Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Registry*
Authors: Simons Jorik , Di Mauro Michele , Mariani Silvia , Ravaux Justine , van der Horst Iwan C. C. , Driessen Rob G. H. , Sels Jan Willem , Delnoij Thijs , Brodie Daniel , Abrams Darryl , Mueller Thomas , Taccone Fabio Silvio , Belliato Mirko , Broman Mike Lars , Malfertheiner Maximilian V. , Boeken Udo , Fraser John , Wiedemann Dominik , Belohlavek Jan , Barrett Nicholas A. , Tonna Joseph E. , Pappalardo Federico , Barbaro Ryan P. , Ramanathan Kollengode , MacLaren Graeme , van Mook Walther N. K. A. , Mees Barend , Lorusso Roberto 
Published: September 2023

OBJECTIVES:
Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) with femoral access is obtained through unilateral or bilateral groin cannulation. Whether one cannulation strategy is associated with a lower risk for limb ischemia remains unknown. We aim to assess if one strategy is preferable.

DESIGN:
A retrospective cohort study based on the Extracorporeal Life Support Organization registry.

SETTING:
ECMO centers worldwide included in the Extracorporeal Life Support Organization registry.

PATIENTS:
All adult patients (≥ 18 yr) who received peripheral venoarterial ECMO with femoral access and were included from 2014 to 2020.

INTERVENTIONS:
Unilateral or bilateral femoral cannulation.

MEASUREMENTS AND MAIN RESULTS:
The primary outcome was the occurrence of limb ischemia defined as a composite endpoint including the need for a distal perfusion cannula (DPC) after 6 hours from implantation, compartment syndrome/fasciotomy, amputation, revascularization, and thrombectomy. Secondary endpoints included bleeding at the peripheral cannulation site, need for vessel repair, vessel repair after decannulation, and in-hospital death. Propensity score matching was performed to account for confounders. Overall, 19,093 patients underwent peripheral venoarterial ECMO through unilateral (n = 11,965) or bilateral (n = 7,128) femoral cannulation. Limb ischemia requiring any intervention was not different between both groups (bilateral vs unilateral: odds ratio [OR], 0.92; 95% CI, 0.82–1.02). However, there was a lower rate of compartment syndrome/fasciotomy in the bilateral group (bilateral vs unilateral: OR, 0.80; 95% CI, 0.66–0.97). Bilateral cannulation was also associated with lower odds of cannulation site bleeding (bilateral vs unilateral: OR, 0.87; 95% CI, 0.76–0.99), vessel repair (bilateral vs unilateral: OR, 0.55; 95% CI, 0.38–0.79), and in-hospital mortality (bilateral vs unilateral: OR, 0.85; 95% CI, 0.81–0.91) compared with unilateral cannulation. These findings were unchanged after propensity matching.

CONCLUSIONS:
This study showed no risk reduction for overall limb ischemia-related events requiring DPC after 6 hours when comparing bilateral to unilateral femoral cannulation in peripheral venoarterial ECMO. However, bilateral cannulation was associated with a reduced risk for compartment syndrome/fasciotomy, lower rates of bleeding and vessel repair during ECMO, and lower in-hospital mortality.