Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation

Chetan Pasrija, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD. Electronic address: cpasrija@gmail.com.
Zachary N. Kon, Department of Cardiothoracic Surgery, Northwell Health, New York, NY.
Michael A. Mazzeffi, Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington, DC.
Jiafeng Zhang, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Zhongjun J. Wu, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Douglas Tran, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Gregory J. Bittle, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Mehrdad Ghoreishi, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Timothy R. Miller, Department of Radiology, Division of Neuroradiology, University of Maryland, School of Medicine, Baltimore, MD.
Hani Alkhatib, Department of Medicine, University of Maryland, School of Medicine, Baltimore, MD.
Nicole Tobin, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Bradley S. Taylor, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Kristopher B. Deatrick, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.
Raymond Rector, Perfusion Services, University of Maryland Medical Center, Baltimore, MD.
Daniel L. Herr, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
Bartley P. Griffith, Division of Cardiac Surgery, University of Maryland, School of Medicine, Baltimore, MD.

Document Type

Journal Article

Publication Date

5-1-2023

Journal

Journal of cardiothoracic and vascular anesthesia

Volume

37

Issue

5

DOI

10.1053/j.jvca.2022.12.025

Keywords

ECMO complications; Extracorporeal membrane oxygenation; Spinal cord injury; Veno-arterial extracorporeal membrane oxygenation

Abstract

OBJECTIVES: There have been sporadic reports of ischemic spinal cord injury (SCI) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. The authors observed a troubling pattern of this catastrophic complication and evaluated the potential mechanisms of SCI related to ECMO. DESIGN: This study was a case series. SETTING: This study was performed at a single institution in a University setting. PARTICIPANTS: Patients requiring prolonged VA-ECMO were included. INTERVENTIONS: No interventions were done. This was an observational study. MEASUREMENTS AND MAIN RESULTS: Four hypotheses of etiology were considered: (1) hypercoagulable state/thromboembolism, (2) regional hypoxia/hypocarbia, (3) hyperperfusion and spinal cord edema, and (4) mechanical coverage of spinal arteries. The SCI involved the lower thoracic (T7-T12 level) spinal cord to the cauda equina in all patients. Seven out of 132 (5.3%) patients with prolonged VA-ECMO support developed SCI. The median time from ECMO cannulation to SCI was 7 (range: 6-17) days.There was no evidence of embolic SCI or extended regional hypoxia or hypocarbia. A unilateral, internal iliac artery was covered by the arterial cannula in 6/7 86%) patients, but flow into the internal iliac was demonstrated on imaging in all available patients. The median total flow (ECMO + intrinsic cardiac output) was 8.5 L/min (LPM), and indexed flow was 4.1 LPM/m. The median central venous oxygen saturation was 88%, and intracranial pressure was measured at 30 mmHg in one patient, suggestive of hyperperfusion and spinal cord edema. CONCLUSIONS: An SCI is a serious complication of extended peripheral VA-ECMO support. Its etiology remains uncertain, but the authors' preliminary data suggested that spinal cord edema from hyperperfusion or venous congestion could contribute.

Department

Anesthesiology and Critical Care Medicine

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