Retrograde perfusion of the dorsalis pedis artery versus traditional distal perfusion catheter use in venoarterial extracorporeal membrane oxygenation

Objective: Limb ischemia is a persistent problem in femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO), with clinically significant adverse events and/or poor outcomes occurring in 10% to 70% of patients. The Extracorporeal Life Support Organization recommends the use of a distal perfusion catheter (DPC), but in patients in whom proximal femoral artery access is challenging or no longer viable, a more distal DPC placement may be necessary. Using a dynamic mock flow loop of adult femoral VA-ECMO, we investigated the hemodynamic feasibility of retrograde dorsalis pedis artery DPC placement versus traditional DPC placement. Methods: An adult femoral VA-ECMO dynamic mock flow loop was tuned to heart failure conditions. An ECMO circuit (Affinity pump with Eurosets oxygenator, 15-Fr arterial cannula in the right common femoral artery, 25-Fr contralateral venous cannula, and 6-Fr pediatric arterial cannula as DPC) was integrated into the loop. Two configurations were tested: (1) traditional anterograde DPC (right superficial femoral artery); (2) retrograde DPC of the right dorsalis pedis artery. Hemodynamic data were collected at baseline (ECMO circuit clamped) and with ECMO support at 0-3000 rpm. Results: Retrograde dorsalis pedis perfusion provided distal limb hemodynamics (pressures, flows) comparable with traditional DPC placement. DPC flow (367 mL/min), right-left limb flow balance ratio, and distal limb pulsatility were comparable with both approaches while maintaining equivalent ECMO and central flows (aortic, venous). The dorsalis DPC provided retrograde flow up the right superficial femoral artery to the proximal limb (147 mL/min) and anterograde flow down the tibioperoneal trunk (252 mL/min). Conclusions: Traditional anterograde DPC is not always feasible in patients with hematoma, obesity, infection, severe peripheral vasculopathy, and/or anatomical variation. We demonstrated experimentally that retrograde DPC of the dorsalis pedis artery may be a viable hemodynamic alternative to traditional DPC placement in femoral VA-ECMO to prevent distal limb ischemia.