Figure 2.

The management of arterial complications induced by ECMO. With a background of systemic inflammatory response, arterial injury can be induced by anatomic injury, mechanical occlusion, thromboembolism with mal-perfusion, and subsequent compartment syndrome. NIRS is a vital component for arterial surveillance on the arterial limb, and distal perfusion catheters (DPC) are an effective preventative strategy. If malperfusion is suspected in the presence of a DPC, the decision of whether the leg ischemia is reversible or irreversible is important early. Imaging, whether by duplex ultrasound or angiogram, can be performed in addition to systemic optimization of the patient to help with the diagnosis. Cannula repositioning and/or placement of a conduit is appropriate if the patient can tolerate a temporary cessation of ECMO. If imaging shows a thrombotic occlusion, open or percutaneous embolectomy is possible. In the presence of a compartment syndrome, fasciotomy of all compartments should be considered early. In the presence of irreversible ischemia, disarticulation at the ankle or knee is a rapid surgery with minimal blood loss and physiological stress that can temporize the patient, allowing for a planned but delayed formalization.