Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review

Table 1 “Participants, Intervention, Comparison, Outcome and Study Design” approach for the selection of clinical studies following systematic search

Participants	Patients undergoing major aortic surgery for aneurysmal disease or dissection
Intervention	VA-ECMO in patients requiring major aortic surgery for aneurysmal disease or dissection
Comparison	Comparison with those who did not need ECMO support
Outcome	If ECMO support made a difference
Study design	Prospective and retrospective clinical studies; case series and case reports

ECMO: Extra-corporeal membrane oxygenation; VA-ECMO: Veno-arterial extracorporeal membrane oxygenation.

Table 2 Grading of manuscripts with key information and outcome

Ref.	Study design/level of evidence	ECMO patients	Outcome
Abouliatim et al[27], 2012	Brief Communication; Level 3	AAA repair on ECMO support in 2 patients after failed EVAR	Both patients were discharged 12 days postoperatively
Lorusso et al[28], 2019	Surgical Technique; Level 3	2 patients requiring elective aortic arch replacement and treated with minimally invasive central ECMO, which avoids re-sternotomy and maintains antegrade blood flow	Successful outcome for both patients. The technique is suitable only in those patients where a side-armed prosthetic graft had been used
Lazar et al[29], 2017	Invited commentary; Level 3	Comment to Sultan, 2017 with further considerations about ECMO in aortic dissection
Guenther et al[30], 2014	Retrospective Case Review; Level 3	6 patients with acute type A aortic dissection involving the coronary arteries treated with ECMO support	Mortality 67% (4 patients)
Lin et al[31], 2018	Observational Study; Level 2-	510 patients with TAAD between 2007 and 2018 17 required ECMO postoperatively	Comparison between low LVEF and preserved LVEF
Lin et al[32], 2017	Retrospective Study; Level 2-	162 patients underwent TAAD repair between 2008 and 2015 20 patients required ECMO support postoperatively	Mortality: ECMO group 65%; non-ECMO group 8.5%
			Factors predicting postop ECMO: haemodynamic instability; aortic cross-clamp time; postop peak creat kinase-MB
			Younger age for ECMO survivors
Zhong et al[33], 2017	Retrospective Study; Level 2-	5637 patients underwent major aortic surgery between 2009 and 2016 36 patients required ECMO support: 20 with TAAD; 3 Type B; 12 with thoracic aortic aneurysm; 1 with CoA (aortic coarctation)	Mortality 50%
			Three main factors for in-hospital mortality: retrograde-flow cannulation; preop CK-MB level 100 IU/L; peak lactate level 20 mmol/L
Sultan et al[34], 2017	Retrospective Study; Level 2-	Database review between 2004 and 2014 35 patients with Type A Aortic Dissection (TAAD) underwent ECMO support	Overall mortality 88%
			There is no mention about indications for ECMO support; profile and co-morbidities of these patients; cannulation site (peripheral or central); cause of death
Guihaire et al[35], 2017	Retrospective Study; Level 2-	92 patients required ECMO support following valve surgery (66%), acute aortic dissection (10%) and CABG (9%)	Survival for patients with aortic dissection is not specified
Gennari et al[36], 2019	Case Report; Level 3	1 patient with iatrogenic type A aortic dissection requiring ECMO support	Successful weaning off ECMO after 4 days
Chatterjee et al[37], 2018	Case Report; Level 3	3 patients requiring ECMO support after thoraco-abdominal aneurysm repair	1 patient discharged after 128 days but died 2 months later
			1 patient discharged after 35 days and alive at 3-year follow up
			1 patient discharged after 19 days and alive at 6-month follow up
Beyrouti et al[38], 2018	Case Report; Level 3	1patient with aortic dissection involving the left main stem requiring ECLS and subsequently LVAD	Discharged after 27 days
Yukawa et al[39], 2018	Case Report; Level 3	Acute aortic dissection with out-of-hospital cardiac arrest requiring ECMO support	Discharged after 49 days
Stroehle et al[40], 2017	Case Report; Level 3	Traumatic aortic dissection treated with TEVAR on ECMO support	Discharged after 42 days to neuro-rehabilitation
Szczechowicz et al[41], 2016	Case Report; Level 3	2 patients with acute type A aortic dissection complicated by right ventricular failure requiring ECMO support	First patient discharged after 27 days; second patient discharged to the ward after 8 days in ITU but no mention about how many days before discharge
Ishida et al[42], 2015	Case Report; Level 3	Two-stage procedure on ECMO support in 1 patient who sustained type A acute aortic dissection in a background of chronic thrombo-embolic pulmonary hypertension	Prolonged hospital stay; no mention how many days before discharge
Yavuz et al[43], 2015	Case Report; Level 3	ECMO following TEVAR in 1 patient	No mention about outcome
Amako et al[44], 2013	Case Report; Level 3	1 patient with type A aortic dissection treated with ECMO support	ECMO weaned off after 65 hours uneventfully
Doguet et al[45], 2010	Case Report; Level 3	1 patient with acute type A aortic dissection involving the coronary arteries treated with ECMO support	Discharged after 29 days postoperatively
Koster et al[46], 2007	Case Report; Level 3	1 patient with acute type A aortic dissection requiring ECMO support who developed HIT treated successfully with bivalirudin	LV recovery during VA-ECMO support but RVAD required. Successful ECMO weaning; RVAD removed after 6 weeks
Fabricius et al[47], 2001	Case Report; Level 3	2 patients who sustained acute type A aortic dissection during pregnancy treated with ECMO support	Successful ECMO weaning
Yamashita et al[48], 1994	Case Report; Level 3	1 patient with acute aortic dissection treated with ECMO support	Successful ECMO weaning
Jorgensen et al[49], 2019	Conference Abstract; Level 3	Elective femoro-femoral VA-ECMO support for thoraco-abdominal aortic aneurysm repair in a 82-year-old patient	Discharged 11 days postoperatively
Heuts et al[50], 2017	Conference Abstract; Level 3	Surgical technique for ECMO insertion (the Maastricht Approach)	See Lorusso, 2019 in this table
Yang et al[51], 2017	Conference Abstract; Level 3	Retrospective analysis of 1695 patients who underwent surgery for aortic dissection between 2008 and 2015. 42 patients required VA-ECMO support	30 patients were successfully weaned off VA-ECMO and 19 patients were discharged.
			Higher lactate levels, pre-ECMO cardiac arrest, major haemorrhage and renal replacement therapy were related to in-hospital mortality
Goldberg et al[52], 2017	Conference Abstract; Level 3	185 patients requiring repair of acute type A aortic dissection between 2005 and 2016. 4 patients required VA-ECMO support.	All 4 patients survived to hospital discharge
Schmidt et al[53], 2016	Conference Abstract; Level 3	Acute type A aortic dissection presenting as acute coronary syndrome requiring ECMO support in the cath lab as a bridge to surgical intervention	Fatal outcome
Nierscher et al[54], 2012	Conference Abstract; Level 3	Observational study of patients undergoing cardiac surgery in 2008. 35 patients required ECMO support. Only one patient with aortic dissection is reported.	Survival not specified for the patient with aortic dissection
Shinar et al[55], 2011	Conference Abstract; Level 3	Observational study over a 14-mo period of ECMO support initiated by A&E physicians. The procedure was attempted in 19 patients	Four patients were discharged without neurological injury: 2 patients after MI, one after aortic dissection with cardiac tamponade and one after profound hypothermia

ECMO: Extra-corporeal membrane oxygenation; ECLS: Extra-corporeal life support; VA-ECMO: Veno-arterial extracorporeal membrane oxygenation.

Table 3 Aetiology, type of procedure and type of cannulation

Ref.	Study design/level of evidence	ECMO patients
Lin et al[31], 2018	Observational Study; Level 2-	510 patients with ATAAD between 2007 and 2018
		Entry Tear Exclusion 73.1%
		Aortic Root Replacement 11.4%
		Ascending Aorta Replacement 65.9%
		Aortic Arch Replacement 25.3%
		Hemiarch 13.3%
		Total Arch 12.0%
		Frozen Elephant Trunk 8.2%
		Combined CABG 3.7%
		17 required ECMO support but no procedure break down is available
Lin et al[32], 2017	Retrospective Study; Level 2-	162 patients underwent type A aortic dissection repair between 2008 and 2015
		20 patients required ECMO support as follows:
		Ascending Aorta Interposition graft 6
		Aortic Root/Valve Procedure 9
		Aortic Arch Procedure 10
		Combined CABG 5
		Combined Mitral Replacement/Repair 1
		Combined Femoro-femoral crossover 1
Zhong et al[33], 2017	Retrospective Study; Level 2-	5637 patients underwent major aortic surgery between 2009 and 2016 36 patients required ECMO support as follows:
		Type A aortic dissection 20
		Type B aortic dissection 3
		Thoracic aortic aneurysm 12
		Aortic coarctation 1
		Emergency surgery 9
		Second operation 7
		Ascending aorta replacement 34
		Arch replacement 21
		Descending aorta atenting 17
		Thoraco-abdominal aorta replacement 2
		Combined valve replacement 21
		Combined CABG 16
		Central ECMO cannulation 7
		Peripheral ECMO cannulation 29
		Femoro-femoral 20
		Femoral vein to right axillary artery 7
		Femoro-femoral + right axillary artery 2
		IABP 9
Sultan et al[34], 2017	Retrospective Study; Level 2-	Database review between 2004 and 2014
		35 patients with type A aortic dissection underwent ECMO support No procedure and cannulation break down is available
Guihaire et al[35], 2017	Retrospective Study; Level 2-	92 patients underwent ECMO support between January 2005 and December 2014 for post-cardiotomy cardiogenic shock as follows:
		Valve surgery 66%
		Acute Aortic Dissection 10%
		CABG 9%
		Break down of procedures and cannulation is not available
Nierscher et al[54], 2012	Conference Abstract; Level 3	35 patients underwent ECMO support in 2008 following CABG (7), valve procedure (8), heart transplant (8), LVAD insertion (1), combined procedure (10), aortic dissection (1).
		Cannulation was peripheral (23), central (7), subclavian artery (5).
Gennari et al[36], 2019	Case Report; Level 3	1 patient with iatrogenic type A aortic dissection requiring ECMO support through peripheral cannulation. Ascending aorta replacement including right coronary sinus with interposition graft and single-vessel coronary artery bypass grafting.
Jorgensen et al[49], 2019	Conference Abstract; Level 3	1 patient with thoraco-abdominal aortic aneurysm requiring ECMO support through peripheral cannulation. A multi-branched Gelweave Dacron graft was used.
Chatterjee et al[37], 2018	Case Report; Level 3	3 patients requiring ECMO support after thoraco-abdominal aneurysm repair.
		2 patients had previous type A aortic dissection repair; 1 patient had ascending aorta and hemiarch replacement for type A aortic dissection and subsequent TEVAR procedure. ECMO cannulation between left axillary artery and femoral vein (1 patient), femoro-femoral (2 patients).
Beyrouti et al[38], 2018	Case Report; Level 3	1 patient with aortic dissection involving the left main stem treated with ascending aorta interposition graft and CABG requiring ECLS through central cannulation and subsequently LVAD
Yukawa et al[39], 2018	Case Report; Level 3	Acute aortic dissection with out-of-hospital cardiac arrest requiring ECMO support through peripheral percutaneous femoral cannulation and treated with ascending aorta replacement using an interposition graft
Yang et al[51], 2017	Conference Abstract; Level 3	1695 patients underwent repair for aortic dissection between 2008 and 2015. 42 patients required ECMO support. Procedure and cannulation break down is not available
Goldberg et al[52], 2017	Conference Abstract; Level 3	185 patients underwent surgical intervention for acute type A aortic dissection between January 2005 and May 2016. 4 patients required VA-ECMO support. Break down of procedures, concomitant procedures and type of cannulation are not available
Stroehle et al[40], 2017	Case Report; Level 3	Traumatic aortic dissection treated with TEVAR on ECMO support
Schmidt et al[53], 2016	Conference Abstract; Level 3	Emergency ECMO insertion in the Cath Lab with findings of type A acute aortic dissection resulting in fatal outcome
Szczechowicz et al[41], 2016	Case Report; Level 3	2 patients with acute type A aortic dissection complicated by right ventricular failure requiring ECMO support
Ishida et al[42], 2015	Case Report; Level 3	Two-stage procedure on ECMO support in 1 patient who sustained acute type A aortic dissection in a background of chronic thrombo-embolic pulmonary hypertension
Yavuz et al[43], 2015	Case Report; Level 3	ECMO following TEVAR in 1 patient
Guenther et al[30], 2014	Retrospective Case Review; Level 3	6 patients with acute type A aortic dissection involving the coronary arteries treated with ECMO support
Amako et al[44], 2013	Case Report; Level 3	1 patient with acute type A aortic dissection treated with ECMO support
Abouliatim et al[27], 2012	Brief Communication; Level 3	AAA repair on ECMO support in 2 patients after failed EVAR
Shinar et al[55], 2011	Conference Abstract; Level 3	19 cases of ECMO insertion in Accident & Emergency Department through percutaneous cannulation of the femoral vessels
Doguet et al[45], 2010	Case Report; Level 3	1 patient with acute type A aortic dissection involving the coronary arteries treated with peripheral ECMO support through femoro-femoral cannulation. CABG as concomitant procedure.
Koster et al[46], 2007	Case Report; Level 3	1 patient with acute type A aortic dissection requiring ECMO support using bivalirudin
Fabricius et al[47], 2001	Case Report; Level 3	2 patients who sustained acute type A aortic dissection during pregnancy treated with ECMO support
Yamashita et al[48], 1994	Case Report ; Level 3	1 patient with acute aortic dissection treated with ECMO support

ATAAD: Acute type A aortic dissection; ECMO: Extra-corporeal membrane oxygenation; TEVAR: Thoracic endo-vascular aortic repair; AAA: Abdominal aortic aneurysm; EVAR: Endo-vascular aortic repair.