Open Repair not a must - Bedside VA Decannulation is Feasible,Safe and Effective

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Abstract Summary
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Authors (including presenting author) :
Au SY(1), Chan KS(2), KM Fong(1), Cheung YCV(1), Luk SF(1), Leung PWR(1), Shek KCJ(1), Yuen HJ(1), Yung SK(1), Sin KC (1), Wu HLH(1), Ng WYG(1), So SO(1), Leung KHA(1)
Affiliation :
(1) Intensive Care Unit, Queen Elizabeth Hospital (2) Department of Surgery, Queen Elizabeth Hospital
Introduction :
VA ECMO is a form of mechanical circulatory support for patients in cardiogenic shock. Blood is drained via from the femoral vein and pumped back to the femoral artery through two large bore catheters. When the heart recovers, the ECMO catheters can be removed. While the venous wound can be managed by manual compression, the femoral artery wound, which accommodates a 15 to 17 Fr catheter, conventionally needs open repair in the operation theater. This is the standard practice in ECMO centers worldwide. Our group performed a retrospective review on VA ECMO decannulation, and found that this practice significantly delays VA ECMO weaning due to limitation of OT theaters or surgeons’ availability, especially during holidays and non-office hours. JW Hwang et al. reported the use of per-cutaneous closure device to close ECMO arterial wound, which was non-inferior, safe and time-saving compared with conventional open repair. It is a device to close vascular wounds by sutures through guide-wire, exempting the need for open repair.
Objectives :
To assess if per-cutaneous closure is safe and effective
Methodology :
After detailed planing, training and collaboration, the first per-cutaneous closure was performed in October 2018. This was performed in the operation theatre for easy conversion to open in case of failure. Subsequently there were 3 more VA ECMO cases by end of 2018 successfully decannulated by the bedside. Their results were analysed.
Result & Outcome :
All 4 were done on the same day the patients declared fit for decannualtion. 2 devices were needed for 2 cases and 3 devices needed for the other 2. The closure took 55 to 65 minutes, which was much faster than the average of 2 hours for open repair. The mean blood loss was 213ml. One of the bedside closure was done on a Sunday morning, and one on Boxing Day, when there were long OT waiting lists. No immediate or subsequent complications including wound haematoma or limb ischaemia were noted. Percutaneous closure of VA ECMO is feasible, safe and can potentially save OT time, manpower and the ECMO days. Clinical audit, simulation training and guidelines are available to ensure its safe and effective application.

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