Migrated Avalon Veno-Venous Extracorporeal Membrane Oxygenation Cannula: How to Adjust Without Interruption of Flow

Abstract

The Avalon dual lumen cannula is presently the cannula of choice for veno‐venous extracorporeal membrane oxygenation (VV‐ECMO) via right internal jugular cannulation. This cannula establishes VV‐ECMO with a single cannulation; however, it requires appropriate positioning to gain adequate oxygenation. Malposition of this cannula can cause inadequate ECMO flow, hypoxia, and structural injury. We have experienced two cases of migration: one into the hepatic vein and the other into the right ventricle. The former was repositioned using echocardiographic guidance without using a guidewire. The latter was repositioned using a guidewire from the femoral vein under fluoroscopy, without antegrade wire placement into the Avalon cannula, discontinuation of ECMO, or bleeding.

“Awake” extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering

“…Positioning bicaval dual-lumen catheters is a major challenge and fluoroscopy and/or transesophageal echocardiography are usually needed to guarantee the correct placement [ 41 – 43 ]. Of note, both ventricular rupture during placement and displacement of the cannula into the right ventricle or hepatic veins during ECMO support, with consequent inadequate ECMO blood flow and reduced respiratory support, have been described [ 44 , 45 ]. As cannula displacement could be related to activity/agitation of patients, the use of bicaval dual-lumen cannulae should be done with caution in potentially agitated patients or patients with extremely severe respiratory failure.…”

Management of cardiopulmonary assist devices in critically ill patients using point-of-care transthoracic echocardiography: a case series

“…The advantages of this cannula include less recirculation, improved patient mobility, and decreased risk of infection. However, this catheter like other ECMO catheters when improperly positioned can lead to recirculation, arrhythmias, and a decrease in ECMO flows resulting in hypoxia [ 7 , 8 ].…”

“…To date, there are only a few published reports detailing its use in the critical care setting with regard to monitoring of patients with cardiovascular/cardiopulmonary assist devices [ 6 – 8 ]. In the following two case reports, we present the use of POC TTE by the intensive care physicians that resulted in immediate changes in the management of critically ill patients requiring cardiopulmonary mechanical device support.…”

Veno-Venous Extracorporeal Membrane Oxygenation (V V ECMO): Indications, Preprocedural Considerations, and Technique

“…Now with our routine use of fluoroscopy for cannulation, we have not experienced any additional incidences of malposition of the cannula. However, there have been five incidences of cannula migrations, which required reposition of the cannula under either fluoroscopy or ultrasound . No patient required conversion to the VA ECMO or extravenous cannula in addition to the Avalon cannula system.…”