JAAOS - 2026-09-10 - Journal Article
Atraumatic Compartment Syndrome in Patients on Extracorporeal Membrane Oxygenation: A Case Series.
Honig RL, Pfaffenbach KA, Thompson AL, Khanna A, Hidden KA, Cross WW, Tangtiphaiboontana J, Sems SA, Yuan BJ
Topics
Key Takeaway
Among 41 ECMO patients who developed atraumatic compartment syndrome, in-hospital mortality was 54%, amputation occurred in 16% of survivors, and 74% of survivors had persistent neurological deficits.
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Summary
This single-institution retrospective series identified 41 patients who developed atraumatic compartment syndrome while on VA-ECMO between 2005 and 2023, all treated with fasciotomy. Compartment syndrome was diagnosed clinically in all cases, with confirmatory pressure measurement in only 41%; mean time from cannulation to diagnosis was 2 days. In-hospital mortality was 54%, and among the 19 survivors, 16% required amputation and 74% had persistent neurological deficits including foot drop.
Key Limitation
Purely clinical diagnosis without systematic compartment pressure measurement in 59% of cases introduces significant diagnostic heterogeneity and makes it impossible to determine whether earlier pressure-guided intervention would alter limb or survival outcomes.
Original Abstract
INTRODUCTION
Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure used to treat cardiopulmonary failure. Atraumatic extremity compartment syndrome is a known complication of limb ischemia related to thrombi from ECMO cannulation, prolonged hypotension, and pressor use. The purpose of this study is to describe a series of patients at a single institution who developed atraumatic compartment syndrome on ECMO.
METHODS
A retrospective review was done at a single academic center between January 1, 2005, and October 30, 2023. The inclusion criteria were clinical diagnosis of compartment syndrome not attributable to trauma (ie, crush injury, fracture, traumatic vascular injury) while on ECMO, which was treated with fasciotomy. Data were collected on patient demographics, clinical course, and limb outcomes.
RESULTS
A total of 41 patients met the inclusion criteria. Average time to diagnosis of compartment syndrome after cannulation was 2 ± 2 days. All patients received VA-ECMO. The majority (36 patients, 88%) underwent peripheral cannulation through the femoral artery (35 patients) or axillary artery (1 patient). All patients were diagnosed clinically, although 17 patients (41%) had confirmatory compartment pressures taken intraoperatively. Fasciotomies were conducted in every case. Postoperatively, 19 patients (46%) developed an acute kidney injury, and 15 (37%) required dialysis. Twenty-two patients (54%) died before discharge. Of the surviving 19 patients, 3 (16%) underwent amputation of the affected extremity, and 14 (74%) had some form of persistent neurological deficits (loss of sensation, muscle weakness, or persistent foot drop).
CONCLUSION
Patients on ECMO who develop compartment syndrome have a high rate of in-hospital mortality, limb loss, and long-term limb deficits. Prompt clinical diagnosis and treatment is critical. There should be a high index of suspicion for patients undergoing VA-ECMO, especially with femoral artery cannulation.