Background

Cerebral perfusion may change depending on arterial cannulation site and may affect the incidenceof neurologic adverse events in post‑cardiotomy extracorporeal life support (ECLS). The current study comparespatients’ neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillaryvs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications.

Methods

This retrospective, multicenter (34 centers), observational study included adults requiring post‑cardiotomyECLS between January 2000 and December 2020 present in the Post‑Cardiotomy Extracorporeal Life Support (PELS)Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidenceof a composite neurological end‑point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomeswere overall in‑hospital mortality, neurologic complications as cause of in‑hospital death, and post‑operative minorneurologic complications (seizures). Association between cannulation and neurological outcomes were investigatedthrough linear mixed‑effects models.

Results

This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397)and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hyper‑tension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke.Neuro‑monitoring was used infrequently in all groups. Major neurologic complications were more frequentin Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001)also after mixed‑effects model adjustment (OR 1.53 [95% CI 1.02–2.31], p = 0.041). Seizures were more commonin Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In‑hos‑pital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral:n = 587, 58.9%, p < 0.001), as shown by Kaplan–Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%,Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar.

Conclusions

In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higherrates of major neurologic complications and seizures. In‑hospital mortality was higher after Aortic cannulation,despite no significant differences in incidence of neurological cause of death in these patients. These results encour‑age vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.