Safely repositioning dual-lumen ECMO cannulas with a transfemoral lasso snare

Abstract

Introduction: Dual-lumen cannulas were designed to provide venovenous extracorporeal membrane oxygenation (VV ECMO) with single-vessel access. Anatomic and size considerations may make appropriate placement challenging in children. Dual-lumen cannulas are repositioned in 20–69% of pediatric patients, which can be difficult without transient discontinuation of ECMO support. Methods: We repositioned three dual-lumen ECMO cannulas introduced via the right internal jugular vein using a transfemoral snare technique under real-time ultrasound and fluoroscopy. Results: Two of three patients were supported on VV ECMO and one on veno-veno-arterial (VV-A) ECMO. Two of the three patients had their dual-lumen cannula repositioned under ultrasound and fluoroscopy guidance and one was repositioned just with ultrasound. No patient experienced a complication from the transfemoral snare technique such as femoral hematoma, hemorrhage or limb ischemia. Conclusion: We describe three patients who successfully had dual-lumen cannulas repositioned without cessation of ECMO using a transfemoral “lasso” technique.

Early computed tomography after extracorporeal cardiopulmonary resuscitation on in-hospital survival: a retrospective cohort study

“…Today, ultrasound is used more often in the ICU than it was in the past. Ultrasound can make many useful contributions, such as confirming the position of an ECMO catheter ( 19 ) and detecting CPR-related injuries by a standard or extended focused assessment with sonography in trauma examinations ( 20 , 21 ); thus, it is less urgent to perform a CT scan post-CPR than it used to be. Additionally, in patients with hemodynamic instability, ultrasound can provide acceptable imaging and has considerable advantages over CT ( 22 ).…”

Strategies for appropriate positioning and repositioning the Avalon ECMO cannula in a 17-year-old with left hepatic vein malposition

“…There are several techniques described in the literature for repositioning. O'Neil et al 6 used the transfemoral lasso snare technique to reposition the cannula under fluoroscopy (2-month-old, 13 Fr) and another with real-time ultrasound (3-month-old, 13 Fr). A similar snaring concept was used for repositioning by Chen et al 19 in a 3-month-old.…”

“…5 For optimal performance, precise placement is required, which can be challenging in children due to anatomy and the cannula size, with mal-positioning occurring in about half of cases. 6 As many as 69% of mal-positioned cannulas may require repositioning. 6 Associated complications include migration into the hepatic vein, which may result in inadequate venous return and hemodynamic support, requiring reposition or potentially retraction of the cannula with conversion to VA ECMO with placement of a separate arterial cannula and use of the arterial side of the VVDL cannula as additional venous return.…”

“…6 As many as 69% of mal-positioned cannulas may require repositioning. 6 Associated complications include migration into the hepatic vein, which may result in inadequate venous return and hemodynamic support, requiring reposition or potentially retraction of the cannula with conversion to VA ECMO with placement of a separate arterial cannula and use of the arterial side of the VVDL cannula as additional venous return. 7 Furthermore, a life-threatening complication is cardiac perforation, which may result from the guidewire looping into the right atrium or right ventricle leading to the introducer damaging the heart and pericardial tamponade.…”

Use of Image Guidance During Pediatric Venovenous Extracorporeal Membrane Oxygenation Cannulation: A Survey of the American Pediatric Surgical Association

“…1 Specifically, the use of BCDL VV-ECMO cannulas decreased invasiveness of cannulation, decreased the time required for cannulation, lowered the risk of line infection compared to two-site cannulation with a groin cannula, [1][2][3] improved patient mobility, 4 and, most importantly, allowed cannulation in smaller children whose femoral veins were unable to accommodate adequately sized drainage cannulas. 5 However, despite these significant advances, some have raised concern that complications during cannulation, such as cardiac injury [6][7][8][9][10][11] and the need to reposition the cannula after placement 1,12 are increased with BCDL VV-ECMO cannulas. 11 The Extracorporeal Life Support Organization (ELSO) registry reports that there is a 15% incidence of cannula complications in pediatric respiratory ECMO cases, and the survival rate decreases from 64% to 51% when these are present, 13,14 clearly illustrating the impact these issues have on delivery of quality ECMO.…”