120 I. Condello: J Extra Corpor Technol 2025, 57, 119--122
transportation time is greater than 15 min [ 2 ]. However, as reviewed by Capoccia and Maybauer, literature on the effectiveness of VA ECMO in this specific setting is scant and mixed, with studies indicating both potential benefits and significant challenges. Their systematic review reveals no conclusive evidence for or against ECMO’ s routine use in major aortic surgery but suggests its cautious application might be justified, particularly in refractory cases where conventional therapies fail [ 2 ]. The controversial nature of ECMO’ s role in ATAAD treatment is further complicated by technical considerations and the variability in outcomes associated with its use. For example, peripheral VA ECMO may increase left ventricular afterload, which requires careful management to optimize beneficial effects and minimize potential harm. The combined use of VA ECMO with other mechanical support devices like an Intra- Aortic Balloon Pump( IABP) or Impella has been explored as a strategy to reduce mortality, suggesting a multifaceted approach might be necessary for optimal patient management [ 3, 4 ]. While VA ECMO offers a potential lifeline for patients with severe ATAAD and malperfusion syndrome, its application should be carefully considered within the context of an integrated treatment strategy tailored to individual patient conditions.
Materials and methods
This narrative review was conducted to explore the role of peripheral veno-arterial extracorporeal membrane oxygenation( VA ECMO) in the management of acute Type A aortic dissection( ATAAD), with a specific focus on malperfusion syndrome and its potential application as a bridge to surgery. A comprehensive literature search was performed using the PubMed and Embase databases, covering publications from January 2000 to March 2025. The search strategy included a combination of free-text terms and Medical Subject Headings( MeSH) such as:“ ECMO” OR“ Extracorporeal Membrane Oxygenation”,“ Type A Aortic Dissection”,“ Acute Aortic Syndrome”,“ malperfusion”,“ bridge to surgery”,“ hemodynamic support”, and“ organ protection”. No language restrictions were applied, provided that an abstract was available in English. Although this is a narrative review, the methodology was informed by the PRISMA( Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The aim was to integrate current evidence into a reasoned proposal for its application as a supportive strategy in selected ATAAD cases.
Results
A total of 10 relevant articles were identified and selected for inclusion. These consisted of observational studies, case series, systematic reviews, and technical reports that addressed the use of VA ECMO in the setting of ATAAD. The initiation of Peripheral VA ECMO in patients diagnosed with acute ATAAD represents a critical decision point that impacts the overall outcome. The primary goal is to establish ECMO support as quickly as possible following the diagnosis, provided that comprehensive imaging confirms the absence of iliac and femoral artery involvement in the dissection. This ensures that the chosen cannulation sites are safe and that the ECMO can provide effective circulatory support without exacerbating the dissection.
1. Imaging and Assessment: Before VA ECMO is initiated, a detailed assessment through imaging, typically a CT angiography, is essential. This imaging must confirm that the iliac and femoral arteries, common sites for ECMO cannulation, arefreefrominvolvementbythedissection. Theintegrity of these vessels is crucial, as cannulation in a dissected vessel can lead to catastrophic complications, including extension of the dissection or complete vessel rupture [ 2 ].
2. Rapid Deployment: Once safe cannulation pathways are confirmed, the rapid deployment of ECMO is vital. The window from diagnosis to ECMO initiation is a critical period where the patient’ s condition can deteriorate quickly. Fast and effective ECMO deployment helps stabilize the patient’ s hemodynamics, providing a bridge to surgical intervention while preventing end-organ damage due to decreased perfusion [ 5 ].
3. Preventive Strategy: The use of ECMO in ATAAD is not only about immediate survival but also about preventing further complications. By maintaining systemic circulation and oxygenation, ECMO helps prevent malperfusion to vital organs, which may not yet be symptomatic but could fail rapidly if blood flow is not restored or supported [ 6 ].
4. Coordination of Care: Implementing ECMO requires coordinated care between multiple ECMO teams, including perfusionists, cardiothoracic surgery, cardiology, critical care, and vascular surgery [ 5 ]. This multidisciplinary approach is essential for ensuring that ECMO is initiated safely, timely, and effectively and that the patient is rapidly transitioned to definitive surgical repair as soon as they are stabilized [ 7 ].
Discussion
The period from Peripheral VA ECMO initiation to surgery represents a critical window that must be managed with precision. Rapid deployment of ECMO followed by swift surgical intervention is essential to minimize risks such as bleeding and thrombotic complications associated with prolonged ECMO support [ 2 ]. Importantly, the quick transition to surgery is not only a matter of reducing ECMO-related complications but is also crucial for addressing the root cause of the dissection before significant anatomical and physiological deterioration occurs [ 7, 8 ]. Moreover, peripheral ECMO can increase myocardial workload, which necessitates a careful balance between preventing malperfusion and avoiding excessive cardiac strain. In the setting of ATAAD, where the heart may already be under considerable stress due to compromised aortic integrity and altered hemodynamics, ECMO provides critical support by mechanically offloading the heart [ 9 ].
VA ECMO as a bridge to surgery and malperfusion prevention
VA ECMO serves an indispensable role in the management of ATAAD by providing hemodynamic stability and