Poster 005: Access-Related Vascular, Bleeding, and Device Complications During ECMO and Their Impact on Outcomes: A National Inpatient Sample Analysis, 2018–2022

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly utilized for shock and advanced cardiopulmonary failure. However, large-bore cannulation and device support carry substantial risk for access-related vascular, bleeding, and device complications. Contemporary national estimates of these complications and their associated outcomes remain limited.

Methods: We conducted a retrospective cohort study using the National Inpatient Sample (NIS) from 2018–2022, identifying adult hospitalizations involving ECMO. Patients were stratified by the presence of any access-related complication, including acute limb ischemia or arterial thrombosis, pseudoaneurysm, arteriovenous fistula, retroperitoneal hematoma or hemoperitoneum, post-procedural bleeding, cardiac or vascular device complications, and hemolysis. Primary outcomes were in-hospital mortality, length of stay (LOS), and inflation-adjusted total hospital charges (2022 USD). Secondary outcomes included stroke, sepsis, blood transfusion, and lower extremity amputation. Survey-weighted regression models adjusted for demographics, payer status, income quartile, hospital characteristics, year, and comorbidities.

Outcome: Among 65,210 ECMO hospitalizations, 21.88% were complicated by at least one access-related event. The most frequent complications were cardiac or vascular device complications (13.00%), acute limb ischemia (4.04%), post-procedural bleeding (3.51%), and retroperitoneal hematoma or hemoperitoneum (2.88%). Compared with patients without access complications, those with complications had higher unadjusted in-hospital mortality (48% vs 42%), longer median LOS (25 vs 20 days), and higher median hospital charges ($1,037,195 vs $755,786; all p< 0.001). After adjustment, access-related complications were independently associated with increased in-hospital mortality (adjusted odds ratio [aOR] 1.20, 95% CI 1.10–1.31), corresponding to an absolute mortality increase of 4.38 percentage points (95% CI 2.25–6.51), as well as higher odds of stroke (aOR 1.36, 95% CI 1.18–1.57) and blood transfusion (aOR 1.12, 95% CI 1.01–1.25). Sepsis was not significantly associated (aOR 1.08, p=0.126). Access complications were also associated with substantially greater resource utilization, including longer LOS (LOS ratio 1.33) and higher hospital charges (charge ratio 1.28; both p< 0.001). Lower extremity amputation was uncommon overall (~0.7%) but occurred more frequently in patients with access complications (unadjusted OR 1.94).

Conclusion: Access-related complications occur in more than one in five ECMO hospitalizations and are independently associated with higher mortality, stroke, transfusion requirements, and markedly increased LOS and costs. These findings underscore the need for standardized cannulation strategies, active vascular surveillance, and early intervention pathways to reduce access-related morbidity in ECMO-supported patients.