同时置入6 F血管鞘用于远端灌注在股动静脉体外膜肺氧合中安全性及有效性的评估

Safety and efficacy of simultaneous placement 6 F vascular sheaths for distal perfusion in femoral arteriovenous V-A ECMO

目的探讨在股静脉-动脉体外膜肺氧合(venous-arterial extracorporeal membrane oxygenation,V-A ECMO)装机过程中同时置入6 F血管鞘进行下肢远端灌注的有效性及安全性。方法收集2018年8月至2021年4月在湖南省人民医院实行股动-静脉穿刺置管的V-A ECMO治疗患者共53例,将在装机的同时使用6 F血管鞘远端灌注和未进行远端灌注或在发现动脉插管侧肢体缺血表现后再进行远端灌注的患者分为血管鞘组(n=19)和对照组(n=34)。分析两组患者临床特点、成功装机所耗时间、肢体并发症发生率、总体病死率、需要连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)支持比率及CRRT支持患者存活率等差异。结果血管鞘组及对照组成功撤机率分别为63.2%(12/19)、61.8%(21/34)(χ2=0.01,P=0.92),存活出院率分别为57.9%(11/19)、47.1%(16/34)(χ2=0.57,P=0.45)。两组成功装机耗时分别为(28.08±9.44)min、(26.40±12.13)min(Mann Whitney Z=0.38,P=0.70)。两组中需要进行CRRT治疗的分别为21.1%(4/19)、35.3%(12/34)(χ2=1.17,P=0.28)。两组CRRT支持的存活出院率分别为10.5%(2/19)、2.9%(1/34)(P=0.25)。穿刺部位出血血管鞘组4例,对照组7例(χ2=0.01,P=0.96)。出现因动脉插管原因导致的单侧下肢缺血血管鞘组及对照组分别为1例(5.26%)和10例(29.41%)(χ2=4.32,P=0.03)。存活出院后置管侧肢体出现异常的情况:血管鞘组未发现可能与动脉插管相关的后遗症,对照组出现4例股动脉插管侧远端肢体乏力,检查发现有腓总神经脱髓鞘样病变,1例患者因ECMO治疗期间下肢缺血坏死进行了截肢手术,存活出院患者总体下肢缺血后遗症比率分别为0、14.7%(P=0.07)。1例患者灌注管与连接管相接处有血栓形成。两组均没有出现明显过度灌注及远端动脉血栓栓塞表现。结论在装机过程中同时使用6 F血管鞘用于股V-A ECMO中的远端灌注是安全、有效的,可以降低出院患者肢体导管相关性缺血并发症发生率。但它对于提高生存率及降低CRRT的使用率未表现出显著性优势。

Objective To investigate the efficacy and safety of 6 F vascular sheath in distal perfusion of lower extremity during femoral arteriovenous V-A ECMO installation.Methods A total of53 V-A ECMO cases of femoral arteriovenous catheterization in our hospital from August 2018 to April2021 were collected.The use of 6 F vascular sheaths for distal perfusion at the same time was defined as the vascular sheath group.Distal perfusion was not performed or distal perfusion was performed after ischemia of the limb of the arterial cannula were defined as the control group.Vascular sheath group has 19cases,control group has 34 cases.To analyze the difference of cases characteristics,time for successful installation,incidence of limb complications,overall mortality,CRRT support ratio and survival rate of CRRT support between the two groups.Results The rate of successfully weaned from ECMO in vascular sheath group and control group was 63.2%(12/19)and 61.8%(21/34)(χ2=0.01,P=0.92),the survival and discharge rates were 57.9%(11/19)and 47.1%(16/34)(χ2=0.57,P=0.45).The time of successful installation in the two groups was(28.08±9.44)min and(26.40±12.13)min(Mann Whitney Z=0.38,P=0.70).CRRT treatment was required in both groups 21.1%(4/19)and 35.3%(12/34)(χ2=1.17,P=0.28).CRRT support survival and discharge rates were 10.5%(2/19)and 2.9%(1/34)(P=0.25).4 cases of bleeding in puncture sits in vascular sheath group and 7 cases in control group(χ2=0.01,P=0.96).There were 1(5.26%)and 10(29.41%)cases single lower limb ischemia due to arterial intubation in the vascular sheath group and the control group(χ2=4.32,P=0.03).Sequelae of intubated limb at post-survival:No sequelae that might be associated with arterial intubation were found in the vascular sheath group.In control group,4 cases of femoral artery intubation side of the distal limb fatigued,found demyelinating lesions of common peroneal nerve.One patient underwent amputation due to lower limb ischemic necrosis during ECMO treatment.The rates of ischemic sequela of lower limbs in the patients who survived and discharged from hospital were 0 and 14.7%(P=0.07).Thrombosis occurred at the junction of perfusion tube and junction tube in 1 patient.There was no obvious hyperperfusion and distal arterial thromboembolism in both groups.Conclusions Simultaneous placement 6 F vascular sheaths for distal perfusion in femoral arteriovenous V-A ECMO is safe and effective,can reduce the incidence of limb catheter-related ischemic complications in discharged patients.However,it showed no significant advantage in improving survival rate and reducing CRRT utilization rate.