Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation

Chetan Pasrija; Zachary N Kon; Michael A Mazzeffi; Jiafeng Zhang; Zhongjun J Wu; Douglas Tran; Gregory J Bittle; Mehrdad Ghoreishi; Timothy R Miller; Hani Alkhatib; Nicole Tobin; Bradley S Taylor; Kristopher B Deatrick; Raymond Rector; Daniel L Herr; Bartley P Griffith

doi:10.1053/j.jvca.2022.12.025

Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation

Chetan Pasrija, Zachary N Kon, Michael A Mazzeffi, Jiafeng Zhang, Zhongjun J Wu, Douglas Tran, Gregory J Bittle, Mehrdad Ghoreishi, Timothy R Miller, Hani Alkhatib, Nicole Tobin, Bradley S Taylor, Kristopher B Deatrick, Raymond Rector, Daniel L Herr, Bartley P Griffith

Research output: Contribution to journal › Article › peer-review

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/m2. 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.

Original language	English
Pages (from-to)	758-766
Number of pages	9
Journal	Journal of cardiothoracic and vascular anesthesia
Volume	37
Issue number	5
DOIs	https://doi.org/10.1053/j.jvca.2022.12.025
State	Published - Apr 2023
Externally published	Yes

Keywords

Humans
Extracorporeal Membrane Oxygenation/adverse effects
Spinal Cord Injuries/diagnostic imaging
Spinal Cord Ischemia/diagnostic imaging
Hypoxia/etiology
Infarction
Retrospective Studies

Access to Document

10.1053/j.jvca.2022.12.025

Cite this

Pasrija, C., Kon, Z. N., Mazzeffi, M. A., Zhang, J., Wu, Z. J., Tran, D., Bittle, G. J., Ghoreishi, M., Miller, T. R., Alkhatib, H., Tobin, N., Taylor, B. S., Deatrick, K. B., Rector, R., Herr, D. L., & Griffith, B. P. (2023). Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation. Journal of cardiothoracic and vascular anesthesia, 37(5), 758-766. https://doi.org/10.1053/j.jvca.2022.12.025

Pasrija, C, Kon, ZN, Mazzeffi, MA, Zhang, J, Wu, ZJ, Tran, D, Bittle, GJ, Ghoreishi, M, Miller, TR, Alkhatib, H, Tobin, N, Taylor, BS, Deatrick, KB, Rector, R, Herr, DL & Griffith, BP 2023, 'Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation', Journal of cardiothoracic and vascular anesthesia, vol. 37, no. 5, pp. 758-766. https://doi.org/10.1053/j.jvca.2022.12.025

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title = "Spinal Cord Infarction With Prolonged Femoral Venoarterial 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/m2. 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.",

keywords = "Humans, Extracorporeal Membrane Oxygenation/adverse effects, Spinal Cord Injuries/diagnostic imaging, Spinal Cord Ischemia/diagnostic imaging, Hypoxia/etiology, Infarction, Retrospective Studies",

author = "Chetan Pasrija and Kon, \{Zachary N\} and Mazzeffi, \{Michael A\} and Jiafeng Zhang and Wu, \{Zhongjun J\} and Douglas Tran and Bittle, \{Gregory J\} and Mehrdad Ghoreishi and Miller, \{Timothy R\} and Hani Alkhatib and Nicole Tobin and Taylor, \{Bradley S\} and Deatrick, \{Kristopher B\} and Raymond Rector and Herr, \{Daniel L\} and Griffith, \{Bartley P\}",

year = "2023",

month = apr,

doi = "10.1053/j.jvca.2022.12.025",

language = "English",

volume = "37",

pages = "758--766",

journal = "Journal of cardiothoracic and vascular anesthesia",

issn = "1053-0770",

number = "5",

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TY - JOUR

T1 - Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation

AU - Pasrija, Chetan

AU - Kon, Zachary N

AU - Mazzeffi, Michael A

AU - Zhang, Jiafeng

AU - Wu, Zhongjun J

AU - Tran, Douglas

AU - Bittle, Gregory J

AU - Ghoreishi, Mehrdad

AU - Miller, Timothy R

AU - Alkhatib, Hani

AU - Tobin, Nicole

AU - Taylor, Bradley S

AU - Deatrick, Kristopher B

AU - Rector, Raymond

AU - Herr, Daniel L

AU - Griffith, Bartley P

PY - 2023/4

Y1 - 2023/4

N2 - 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/m2. 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.

AB - 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/m2. 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.

KW - Humans

KW - Extracorporeal Membrane Oxygenation/adverse effects

KW - Spinal Cord Injuries/diagnostic imaging

KW - Spinal Cord Ischemia/diagnostic imaging

KW - Hypoxia/etiology

KW - Infarction

KW - Retrospective Studies

U2 - 10.1053/j.jvca.2022.12.025

DO - 10.1053/j.jvca.2022.12.025

M3 - Article

C2 - 36842938

SN - 1053-0770

VL - 37

SP - 758

EP - 766

JO - Journal of cardiothoracic and vascular anesthesia

JF - Journal of cardiothoracic and vascular anesthesia

IS - 5

ER -