清醒静脉-动脉体外膜氧合动脉闭合策略:ProGlide血管闭合装置后闭合技术优于外科修复

Arterial closure strategy after awake veno-arterial extracorporeal membrane oxygenation decannulation:ProGlide-based post-closure technique is superior to surgical repair

目的探讨基于ProGlide血管闭合装置的后闭合技术在清醒静脉-动脉体外膜氧合(VA-ECMO)拔管中的安全性与有效性。方法回顾性分析2017年1月至2021年6月于我院行清醒VA-ECMO救治并撤机患者的临床结局。根据使用的血管闭合方式,将患者分为ProGlide后闭合技术组(ProGlide组)和外科修复组。分析患者全因住院死亡率、动脉拔管闭合操作时间、出血相关事件、30 d内血管相关并发症等。结果共35例患者最终纳入研究,其中21例(60.0%)使用ProGlide后闭合技术,14例(40.0%)使用外科修复技术。全组患者男21例(60.0%)、女14例(40.0%),平均年龄(49.20±10.52)岁,VA-ECMO支持的中位时间为10.0(8.0,12.0)d,全因住院死亡率为11.4%(4/35)。多因素logistic回归分析结果显示,校正年龄、性别后,在主要观察终点中,两组的全因住院死亡率差异无统计学意义(OR=0.78,95%CI 0.09~6.89,P=0.826)。次要观察终点显示,ProGlide组具有更少的动脉拔管闭合操作时间(β=14.14,95%CI 7.22~21.05,P<0.01)及更短的撤机后ICU停留时间(β=2.11,95%CI 0.20~4.02,P=0.032)。两组均无主要出血事件及30 d内主要血管相关并发症发生,但ProGlide组次要出血事件及30 d内次要血管相关并发症发生率均低于外科修复组(OR=0.13,95%CI 0.02~0.88,P=0.036;OR=0.05,95%CI0.00~0.59,P=0.018)。ProGlide组患者撤机时重症监护室疼痛观察工具法(CPOT)评分明显低于外科修复组(β=1.26,95%CI 0.37~2.14,P=0.007),外科修复组动脉缝合时需要额外使用瑞芬太尼的患者比例明显增加(OR=0.06,95%CI 0.01~0.36,P=0.002)。结论在清醒VA-ECMO动脉拔管过程中,采用ProGlide血管闭合装置的后闭合技术是安全、有效的。与外科修复方法相比,ProGlide血管闭合装置的后闭合技术具有操作时间短、出血及血管相关并发症少、患者疼痛感轻的优势,对促进患者快速康复具有一定作用。

Objective To investigate the safety and effectiveness of the ProGlide-based post-closure technique in awake veno-arterial extracorporeal membrane oxygenation(VA-ECMO)decannulation.Methods The clinical outcomes of patients who received awake VA-ECMO treatment and removed from the machine in our hospital from Jan.2017 to Jun.2021 were retrospectively analyzed.The patients were divided into ProGlide-based post-closure technique group(ProGlide group)and surgical repair group according to the vascular closure method used.All-cause in-hospital mortality,procedure time of arterial closure decannulation,bleeding-related events,and vascular-related complications within 30 d were analyzed.Results A total of 35 patients were eventually enrolled,including 21(60.0%)with ProGlide-based postclosure technique and 14(40.0%)with surgical repair technique.There were 21 males(60.0%)and 14 females(40.0%)with a mean age of(49.20±10.52)years old.The median time of VA-ECMO support was 10.0(8.0,12.0)d,and the all-cause in-hospital mortality was 11.4%(4/35).Multivariate logistic regression analysis showed that after adjusting for age and gender,there was no significant difference in all-cause in-hospital mortality between the 2 groups(odds ratio[OR]=0.78,95%confidence interval[CI]0.09-6.89,P=0.826)at the primary end point.The secondary end point showed the ProGlide group had less procedure time(β=14.14,95%CI 7.22-21.05,P<0.01)and shorter intensive care unit(ICU)length of stay after decannulation(β=2.11,95%CI 0.20-4.02,P=0.032).There were no major bleeding events or major vascular-related complications within 30 d between the 2 groups.The ProGlide group had lower incidence of minor bleeding events or minor vascular-related complications within 30 d than the surgical repair group(OR=0.13,95%CI 0.02-0.88,P=0.036;OR=0.05,95%CI 0.00-0.59,P=0.018).The critical care pain observation tool(CPOT)score of the patients in the ProGlide group was significantly lower than that in the surgical repair group(β=1.26,95%CI 0.37-2.14,P=0.007).The need for remifentanil for arterial suturing was significantly increased in the surgical repair group(OR=0.06,95%CI 0.01-0.36,P=0.002).Conclusion ProGlide-based post-closure technique is safe and effective in the process of awake VA-ECMO decannulation.Compared with surgical repair technique,it has the advantages of shorter procedure time,less bleeding and vascular-related complications,and less pain for patients,and it has a certain role in promoting rapid recovery of patients.