Feasibility and outcomes with subclavian vein access for crescent jugular dual lumen catheter for venovenous extracorporeal membrane oxygenation in COVID-19 related acute respiratory distress syndrome

Abstract

Introduction Femoral-femoral Veno-Venous ExtraCorporeal Life Support (V-V ECLS) has been associated with higher infections rates, vascular site bleeding complications, and restricted patient mobility. Jugular or bicaval dual lumen V-V ECLS conceptually overcomes some of these adverse factors, but experience has shown that jugular vein cannulation still limits mobility and has increased bleeding complications. Technique and outcomes of subclavian vein single-cannulation with Crescent jugular dual-lumen V-V ECLS is described. Method five patients with COVID-19 related acute respiratory distress syndrome (ARDS) underwent right subclavian vein V-V ECLS placement with the Crescent 32 French jugular dual-lumen V-V ECLS catheter. A standardized percutaneous technique was developed that allowed efficient insertion without need for any specialized imaging (i.e. transesophageal echocardiogram) and outcomes assessed. Results Mean age of the five patients was 41.2 years, all obese with an average basal mass index of 45.2 kg/m2 and mean days to decannulation of 24.2 days. Outcomes discovered included; improved patient mobility allowing physical rehabilitation, no vascular access site related complications requiring surgery or endovascular intervention, and none had evidence of superior vena cava syndrome. One patient had subclavian/axillary vein thrombosis with resolution after 3 months of direct-acting oral anticoagulants, and one patient had blood cultures positive at day 37, nearing decannulation. Conclusion Subclavian vein access for crescent jugular dual lumen V-V ECLS catheter appears to be safe and feasible with added benefits of decreased bleeding and increased mobility over jugular or femoral-femoral access site for long term V-V ECLS support in COVID-19 related ARDS patients.

Safety of Supraclavicular Approach for Dual-Lumen Catheter Placement in Veno-Venous Extracorporeal Membrane Oxygenation: A Case Report

“…Memon et al reported a case series of DLC cannulation via the right SV; the procedure was technically feasible and had a favorable safety profile with a low rate of vascular complications and infection. They also described DLC insertion via the right SV as a practical method for patients requiring long-term V-V ECMO support because it allows greater patient mobility than either jugular or femoral access [ 9 ]. However, complications including pneumothorax, hemothorax, and brachial plexus injury are more commonly reported with SV cannulation compared to IVJ [ 10 ].…”

The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians

“…Subclavian-right atrial ((dl)Vsc-Vra): Several centres have reported success using a subclavian approach 31,32 although this is less established. This may be useful in individuals of shorter stature in which there is inadequate space in the neck to site a jugular cannula.…”

“…26 Use of a dual lumen cannula means that this advantage is offset by greater flow limitation as the maximum size of commercially available devices is 31-32Fr [27][28][29] with larger sizes possibly associated with a greater rate of complications, including venous thrombosis. 30 Subclavian-right atrial ((dl)Vsc-Vra): Several centres have reported success using a subclavian approach 31,32 although this is less established. This may be useful in individuals of shorter stature in which there is inadequate space in the neck to site a jugular cannula.…”