A Case Report of A Drop Foot Developed After Common Femoral Artery Cannulation for Venoarterial Extracorporeal Membrane Oxygenation.
Extracorporeal membrane oxygenation (ECMO) is an effective method on the view of a bridge by the recovery of postoperative outcomes of lung transplantation and it was highlighted as an evident in the studies that have been conducted recently (1). On the other hand, complications can be developed with ECMO such as primary mechanical, vascular, renal, lung and neurological. Acute compartment syndrome is a rare complication of ECMO implementation that could be occured as a consequence of developing ischemia or reperfusion impairment of the extremity during application (2). This syndrome is a emergency surgery indication. It may occur in all extremities and body space. It is frequently observed especially with the lower extremities as a result of trauma and less frequently after exposing prolonged compression and vascular injury. The clinical manifestation develops within hours in conclusion of ischemia and necrosis caused by increase of pressure in all tissues within compartment (3).
Twenty-one-year-old female patient (weight: 38 kg, hight: 148 cm, BMI: 17.34) without any neurological and vascular disease who developed severe pain and peripheral edema in the right lower extremity on the first postoperative day following the femoral artery cannulation for venoarterial ECMO performed during the lung transplantation process. Then, the added to the symptoms above cyanosis, ischemia and loss of heat in extremity were observed. It was detected that motor weakness and sensory loss in the right lower limb in the neurological examination by a neurologist on the second postoperative day. Motor loss of strength was as follows; hip flexor 4/5, knee extensor 4/5, ankle dorsiflexor 0/5, great toe extensor 0/5 and ankle plantar flexor 1/5 in the affected limb by Manuel muscle test (Medical Research Council, MRC). In addition, the patient's pulse lost on the popliteal artery and the posterior tibial artery in affected extremity. It suggests that this clinical condition may be acute compartment syndrome; therefore, patient's superficial ultrasound (sUSG) and arterial-venous Doppler ultrasound (dUSG) was performed and forms of patient constent was taken during the hospitalization for all the considerations have been made. Venous structures are within normal limits yet revealed a monophasic flow in the right anterior tibial artery in affected extremity and diameter of common femoral artery was detected 6.3 milimeter by dUSG. Also interstitial edema was found in skin and under the skin soft tissue by sUSG. Lesions detected by magnetic resonance imaging (MRI) showed signal changes in heterogeneous character which they were hypointense on the T1-weighted sequences and hyperintense on T2-weighted sequences, also had intense contrast enhancement, where starting from the middle part of the tibial level in the area extending from proximal to distal medullary and muscles that are located adjacent to this area as tibialis anterior (TA), extensor hallucis longus (EHL), extensor digitorum longus (EDL), peroneus longus (PL), and as more less tibialis posterior (TP), gastrocnemius (GC) in MRI (Figure 1).
We thought that the development of the neurovascular complications after cannulation of the femoral artery and vein due to exceed compartment presure in patient's undergoing ECMO. Then, treatment was initiated after consultations of cardiovascular surgery, physical therapy and rehabilitation in intensive care unit which treatment was nonsteroidal anti-inflammatory treatment, 900 mg/day gabapentin for pain control therapy, further elevation of the extremity and other physical therapy.
Electromyograpic (EMG) examination was performed on the 10th day of developing droop foot in right lower extremity. The results were detected as the right peroneal nerve motor response by recording of the muscle of TA and EDB with the right sural and the right superficial peroneal sensory responses could not be obtained, moreover right tibial nerve compound muscle action potential amplitude was slightly lower in nerve conduction study. In addition, motor unite potentials of EDB, TA and EHL muscles could not be exited during voluntary muscle contraction whereas intense positive spines and fibrillation potentials on theese muscles during rest showed by needle electromyograph. As a result, according to the findings of this EMG, it was decided that acute axonal degeneration as markedly common peroneal nerve and lesser extent tibial nerve in the right distal extremity (Table 1).
Pain and swelling reduce right lower extremities of patient with treatment during clinical follow-up. It was detected a rate of 2/5 dorsal flexion weakness in the right big toe and hypoesthesia on peroneal area of the right foot in the patient's control after treatment in the second months. On the other hand, it was detected that continued intense denervation activity according to the first study on the 10th day and began especially partially reinervation TA muscle in the second month on the patient's control the EMG's.
Extracorporeal membrane oxygenation is generally used in patients that indicated for the management of life-threatening pulmonary or cardiac failure when no other form of treatment has been or is likely to be successful to improve oxygenation (4). The system consists of two vascular cannulas. Venous canul enables the removal circulation outside the body through an artificial lung with a pump. It provided oxygenation of deoxygenated blood in the venous system. Afterwards, oxygenated blood is returned to the circulation using the arterial cannula that it can be venous system either through venovenous method (VV) or the arterial system through venoarterial method (VA) that is generally used in the femoral artery or vein for catheterization (4). The latter representing Femoral VA-ECMO cannulation that is known to provide effective cardiopulmonary support for cardiac and pulmonary patients is preferred on the preoperative or postoperative periyod of lung transplantation (1).
Unfortunately, VA-ECMO pro duces a relatively high risk of complications that include primary mechanical, renal, lung and neurological. The most important factors that could cause complications is underlies etiologies. Neurological complication have been shown more than 30% of patients treated with ECMO in adult (5). Also this ratio was reported as 22% in children (6). Distal limb ischemia is a well documented complication when the femoral VA-ECMO cannulation, and this ratio was reported as 18-30% in adults (7). There are multiple reports describes placement of a small diameter catheter distally to provide antegrade flow to the ischemic limb at the time of initial open ECMO cannulation in adults (8). Also, the distal limb ischemia after applied to femoral VA-ECMO was reported more frequently mainly in children due to artery diameter (9).
As it is known, acute compartment syndrome can develop as a result of limb ischemia or reperfusion during ECMO (2). The anterior compartment is an enclosed space arround rigid walls. When the anterior compartment pressure exceeds the intra-arterial pressure that this will produce venous stasis and also arterial occlusion, it results in muscles swelling and eventually necrosis of muscle and nerves duo to prolonged limb ischaemia. The nerve damage may vary depending on the duration of ischemia and degree of occlusion (10). In this case that developed drop foot in the postoperative period, it was observed necrosis of developed secondary to ischemia, impairment of arterial flow and venous stasis in dUSG in accordance with the EMG and clinical examination. We thought that might be effect small diameter of the femoral artery in the etiology as previously stated in the pediatric literature. In addition to applied longer VA-ECMO during lung transplantation process on the both preoperative and postoperative period can be effective on another important factor for prolonged distal arterial ischemia.
Consequently, acute axonal degeneration of the common peroneal nerve can be improved secondary to distal ischemia as results of increased pressure inside the compartment with stasis and edema occurring during the application VA-ECMO. This is not a rare case particularly in adult individuals with small diameter arteries. it should be noted that the possible neurological complications that may arise during the application VA-ECMO.
Ethics Committee Approval: Ethics committee approval was received from the ethics committee of Yedikule Thorax Diseases and Surgery Training and Research Hospital.
Informed Consent: Written consent was obtained from the patient.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - SA; Design - SA; Supervision - NP, OA, SB, NDB, AS; Resource - SA,NDB, AS; Materials - SA, SB, NDB, AS; Data Collection and/ or Processing - SA, NP, OA; Analysis and/or Interpretation - SA; Literature Search - SA; Writing - SA; Critical Reviews - NP, OA, SB, NDB, AS.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
(1.) Chiumello D, Coppola S, Froio S, Colombo A, Del Sorbo L. Extracorporeal life support as bridge to lung transplantation: a systematic review. Crit Care 2015;19:19. [CrossRef]
(2.) Yeo JH, Sung KH, Chung CY, Lee KM, Choi Y, Kim TG, Kwon SS, Lee SY, Park MS. Acute compartment syndrome after extracorporeal membrane oxygenation. J Orthop Sci 2015;20:444-448. [CrossRef]
(3.) Khan SK, Thati S, Gozzard C. Spontaneous thigh compartment syndrome. West J Emerg Med 2011;12:134-138.
(4.) Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ 2008;17 Suppl 4:S41-S47. [CrossRef]
(5.) Thiagarajan RR, Brogan TV, Scheurer MA, Laussen PC, Rycus PT, Bratton SL. Extracorporeal membrane oxygenation to support cardiopulmonary resusci tation in adults. Ann Thorac Surg 2009;87:778-785. [CrossRef]
(6.) Barrett CS, Bratton SL, Salvin JW, Laussen PC, Rycus PT, Thiagarajan RR. Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation. Pediatr Crit Care Med 2009;10:445-451. [CrossRef]
(7.) Mohite PN, Fatullayev J, Maunz O, Kaul S, Sabashnikov A, Weymann A, Saez DG, Patil NP, Zych B, Popov AF, DeRobertis F, Bahrami T, Amrani M, Simon AR. Distal limb perfusion: Achilles' heel in peripheral venoarterial extracorporeal membrane oxygenation. Artif Organs 2014;38:940-944. [CrossRef]
(8.) Madershahian N, Nagib R, Wippermann J, Strauch J, Wahlers T. A simple technique of distal limb perfusion during prolonged femoro-femoral cannulation. J Card Surg 2006;21:168-169. [CrossRef]
(9.) Haley MJ, Fisher JC, Ruiz-Elizalde AR, Stolar CJ, Morrissey NJ, Middlesworth W. Percutaneous distal perfusion of the lower extremity after femoral cannulation for venoarterial extracorporeal membrane oxygenation in a small child. J Pediatr Surg 2009;44:437-440. [CrossRef]
(10.) Go JY, Min YS, Jung TD. Delayed onset of acute limb compartment syndrome with neuropathy after venoarterial extracorporeal membrane oxygenation therapy. Ann Rehabil Med 2014;38:575-580. [CrossRef]
Senay AYDIN (1) [iD], Nevin PAZARCI 2 [iD], Onur AKAN 3 [iD], Songul BUYUKKALE 4 [iD], Nur Dilek BAKAN 5 [iD], Adnan SAYAR 4 [iD]
(1) Department of Neurology, Yedikule Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
(2) Department of Neurology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
(3) Department of Neurology, Okmeydani Training and Research Hospital, Istanbul, Turkey
(4) Department of Chest Surgery, Memorial Hospital, Istanbul, Turkey
(5) Department of Chest Diseases, Memorial Hospital, Istanbul, Turkey
Correspondence Address: Senay Aydin, Yedikule Gogus Hastaliklari ve Gogus Cerrahisi Egitim ve Arastirma Hastanesi, Noroloji Bolumu, Istanbul, Turkey * E-mail: firstname.lastname@example.org
Received: 22.09.2016, Accepted: 02.12.2016, Available Online Date: 20.04.2018
Table 1. Electromyographic findings NCS Lat [m/s] Amp [[micro]V] R L R L SENSORY Sural (Lat Mall Antidr) 10th day NR 3.90 NR 13.7 1th month NR 3.85 NR 12.1 2nd month NR 2.15 NR 15.1 Sup peroneal (Ankle Antidr) 10th day NR 1.95 NR 11.4 1th month NR 2.01 NR 10.8 2nd month NR 2.10 NR 11.5 MOTOR Comm peroneal R (EDB) RR 10th day NR 3.15/10.15/12.25 NR 4.5/4.5 /4.3 1th month NR 3.05/11.10/11.05 NR 4.8/4.6 /4.5 2nd month NR 3.15/9.15/11.6 NR 4.4/4.4 /4.3 Comm peroneal (Tib Ant) 10th day 1.95/4.40 - 0.2/0.3 - 1th month 2.50/4.40 - 0.4/0.1 - 2nd month 2.15/3.95 - 1.1/1.1 - Tibial (knee) (AH) 10th day 4.10/14.35 4.85/14.10 3.8/3.2 7.1/6.5 1th month 4.05/13.0 4.55/12.35 5.0/3.8 7.0/5.9 2nd month 4.65/14.45 4.20/12.75 6.2/4.9 8.7/8.8 NCS Velocitiy [m/s] R L SENSORY NR 50.8 NR 51.2 NR 46.5 NR 51.8 NR 52.2 NR 47.6 MOTOR R NR 47.6/42.6 RR NR 45.8/44.4 NR 46.7/44.9 42.8 - 41.3 - 55.6 - 41.0 42.2 40.8 41.6 47.4 46.6 EMG SUMMARY TABLE R Spontaneous MUAP Recruitment Fib PSW Fasc Amp Dur. PPP Pattern Quadriceps 10th day None None None N N N N 1th month None None None N N N N 2nd month None None None N N N N Vast lateralis 10th day None None None N N N N 1th month None None None N N N N 2nd month None None None N N N N Tib anterior 10th day 4+ 1+ None NoA NoA NoA NoA 1th month 3+ 3+ None 1+ 1+ 1+ Discrete 2nd month 1+ 1+ None 2+ 3+ 3+ Reduced Peron longus 10th day 1+ None None N N N Reduced 1th month 1+ None None N N N/1+ Reduced 2nd month 1+ None None 1+ 1+ 1+ Reduced Gastrocn (med) 10th day 1+ None None N N N Reduced 1th month 1+ None None N 1+ 1+ N 2nd month N None None N 1+ N N Ext dig brevis 10th day 4+ 4+ None NoA NoA NoA NoA 1th month 4+ 4+ None NoA NoA NoA NoA 2nd month 4+ 4+ None NoA NoA NoA NoA Ext hall long 10th day 4+ 4+ None NoA NoA NoA NoA 1th month 4+ 4+ None NoA NoA NoA NoA 2nd month 4+ 4+ None NoA NoA NoA NoA Tib Posterior 10th day 1+ None None N N N Reduced 1th month 1+ None None N N/1+ N/1+ Reduced 2nd month N None None N N/1+ N/1+ Reduced NoA: No activity
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||CASE REPORT|
|Author:||Aydin, Senay; Pazarci, Nevin; Akan, Onur; Buyukkale, Songul; Bakan, Nur Dilek; Sayar, Adnan|
|Publication:||Archives of Neuropsychiatry|
|Date:||Mar 1, 2019|
|Previous Article:||Guillain-Barre Syndrome and Its Variants: Clinical Course and Prognostic Factors.|
|Next Article:||Olanzapine Associated Acute Peripheral Edema and Pericardial Effusion: A Case Report.|