Mitigating limb ischemia in veno-arterial extracorporeal membrane oxygenation: A narrative review of evolving role of distal perfusion catheters

Table 2 Studies depicting limb ischemia, distal perfusion catheter insertion and outcomes

Ref.	Type of study	Distal perfusion catheter strategy	Limb ischemia incidence	Impact of acute limb ischemia on outcomes
Kaufeld et al[30], 2019	DPC strategy based	Upfront prophylactic (77%) vs none	3.38% with DPC vs 21.42% without DPC	Absence of DPC identified as an independent risk factor for critical limb ischemia (P < 0.001). Authors suggest to have mandatory distal limb perfusion
Lamb et al[6], 2017	DPC strategy based	Upfront prophylactic (60%)	0% with DPC vs 33% without DPC	Survival in patient with ALI was 25% compared to 42% overall survival; only 1 patient required amputation. Continuous monitoring with NIRS suggested if DPC not placed prophylactically
Son et al[2], 2021	DPC strategy based	Selective monitored (44%)	20% incidence of ALI	DPC placement did not significantly reduce the risk of ALI
Liao et al[15], 2020	DPC strategy based	Upfront prophylactic (100%)	20.11% incidence of ALI	Peripheral artery disease was the primary independent risk factor for ALI despite DPC
Hu et al[17], 2022	DPC strategy based	Rescue (only after clinical signs)	Limb ischemia complications were noted in 10.6% of total patients, with 8.4% patients requiring a rescue DPC	Authors suggest to optimize cannulation strategies during establishment of VA-ECMO
Lunz et al[10], 2019	DPC strategy based	Selective monitored (50% of ALI cases)	43.9% incidence of ALI	Cannula size and indication of ECMO noted to be most important factors for development of ALI
Yau et al[14], 2019	DPC strategy based	Upfront prophylactic (29.8%)	22% incidence of ALI	Lack of prophylactic DPC or arterial cannula size not primary drivers of ALI, rather younger patients, history of diabetes and peripheral arterial disease are at increased risk of ALI
Kim et al[31], 2017	ALI monitoring based	Upfront prophylactic (noted as insufficient without NIRS)	ALI incidence not explicitly given for the group	0% fasciotomy rate in NIRS group vs 13.9% in the control group (P = 0.04). Also, the mean time to distal perfusion was shorter in NIRS group, suggesting the early institution of NIRS to be valuable
Vinogradsky et al[32], 2023	ALI monitoring based	Selective monitored (NIRS-guided placement)	Limb ischemia requiring surgical intervention in NIRS group (2.6%) vs non-NIRS group (8.5%)	Continuous NIRS monitoring as guidance for selective insertion of DPC is an effective strategy

DPC: Distal perfusion catheter; ALI: Acute limb ischemia; NIRS: Near-infrared spectroscopy; OR: Odds ratio; ECMO: Extracorporeal membrane oxygenation; VA-ECMO: Veno-arterial extracorporeal membrane oxygenation.