ECMO year in review: Cannulation & cannulae/cannulation related complications

Cannulation strategies for veno-arterial ECMO: each one with distinct benefits & drawbacks! In this paper various techniques and their indications are discussed, from the easier/most conventional ones to more sophisticated and highly demanding strategies, as triple or quadruple cannulation, in cases of combined respiratory/cardiac failure requiring dual organ support, in cases of left ventricular stasis with the need for unloading LV, or to facilitate mobilization and physical conditioning.

Camboni D, Philip A, Schmid C, Loforte A. Double, triple and quadruple cannulation for veno-arterial extracorporeal membrane oxygenation support: is there a limit? Ann Cardiothorac Surg. 2019 Jan;8(1):151-159. Open access link

Choosing ECMO catheters…

Pressure & flow properties of ECMO cannulae: do available informations correspond to in-vivo clinical performance? could testing catheters with whole blood flows be recommended to properly guide clinicians?

part I, return cannulae:
Broman LM, Prahl Wittberg L, Westlund CJ, Gilbers M, Perry da Câmara L, Swol J, Taccone FS, Malfertheiner MV, Di Nardo M, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Müller T, Belliato M, Lorusso R. Pressure and flow properties of cannulae for extracorporeal membrane oxygenation I: return (arterial) cannulae. Perfusion. 2019 Apr;34(1_suppl):58-64. link
& part II, drainage cannulae:

Broman LM, Prahl Wittberg L, Westlund CJ, Gilbers M, Perry da Câmara L, Westin J, Taccone FS, Malfertheiner MV, Di Nardo M, Swol J, Vercaemst L, Barrett NA, Pappalardo F, Belohlavek J, Müller T, Belliato M, Lorusso R. Pressure and flow properties of cannulae for extracorporeal membrane oxygenation II: drainage (venous) cannulae. Perfusion. 2019 Apr;34(1_suppl):65-73. link

& here a letter referring to previous 2 papers, suggesting some “in vivo” considerations when selecting catheters for extracorporeal support: do available informations correspond to in-vivo clinical performance? could testing catheters with whole blood flows be recommended to properly guide clinicians?

Giani M, Lucchini A, Rona R, Capalbi S, Grasselli G, Foti G. Pressure-flow relationship of cannulae for extracorporeal membrane oxygenation. Perfusion. 2019 Aug 13:267659119867182. link

Cannulating the ECMO patient

Bedside percutaneous bicaval-double lumen ECMO cannulation performed by experienced intensivists under exclusive transthoracic echo guidance seems feasible, effective, & safe even in newborns/small children according to this retrospective analysis, and could be a valid alternative to surgical cutdown and semi-Seldinger technique. IJV diameter not the only factor influencing choice of cannula size give priority to the one potentially more effective in providing proper blood flow; consider LIJV approach if RIJV not practicable.

Moscatelli A, Febbo F, Buratti S, Pezzato S, Bagnasco F, Lampugnani E, Nuri H, Buffelli F, Grasso C, Castagnola E. Intensivists Performed Percutaneous Bicaval Double-Lumen Echo-Guided Extracorporeal Membrane Oxygenation Cannulation at Bedside in Newborns and Children: A Retrospective Analysis. Pediatr Crit Care Med. 2019 Jun;20(6):551-559. link

Ultrasound & vascular access in the critically ill: prevalence & evidence supporting echo guided CVC insertion, proposal of an algorithmic approach, specific central line insertion technique and US guidance for cannulation at other sites: peripheral veins, arteries, IO access & ECMO cannulae, training. An open access review addressing the state of ultrasound-guided vascular access in the ICU, including current practice & future directions.

Schmidt GA, Blaivas M, Conrad SA, Corradi F, Koenig S, Lamperti M, Saugel B, Schummer W, Slama M. Ultrasound-guided vascular access in critical illness. Intensive Care Med. 2019 Apr;45(4):434-446.open access link

Cannulation strategies

Are patients on veno-arterial extracorporeal life support with carotid artery cannulation at higher risk for ischemic neuro-injuries? Maybe, or maybe not: ASAIO Journal editorial suggesting, until more definitive longer-term follow-up data will reccomend otherwise, to maintain a position of equipoise, selecting vessels for ECMO cannulation not based on fear of stroke risk; regardless of cannulation sites, employ strategies providing both effective support & minimizing severe morbidity, be it brain or limb.

Woods RK. Extracorporeal Life Support and Increased Risk of Stroke with CarotidCannulation: Maybe, Maybe Not. ASAIO J. 2019 Sep/Oct;65(7):635. link

Here the study author refers to, reporting increased likelihood of stroke with cannulation of the carotid artery in patients 6–40 years old vs femoral cannulation for VA ECLS, but also suggesting to consider many other factors when selecting arterial cannulation site.

Di Gennaro JL, Chan T, Farris RWD, Weiss NS, McMullan DM. Increased Stroke Risk in Children and Young Adults on Extracorporeal Life Support with Carotid Cannulation. ASAIO J. 2019 Sep/Oct;65(7):718-724. link

Unconventional approaches

Adjunctive pulmonary artery cannulation on ECMO to provide additional RV drainage or support & LV unload supporting hemodynamic needs as preoperative or intraoperative biventricular or right ventricular dysfunction occurs, allowing for better patient management. Read about this multicenter experience, with detailed description of the technique and results.

Lorusso R, Raffa GM, Heuts S, Lo Coco V, Meani P, Natour E, Bidar E, Delnoij T, Loforte A. Pulmonary artery cannulation to enhance extracorporeal membrane oxygenation management in acute cardiac failure. Interact Cardiovasc Thorac Surg. 2019 Oct 26. open access link

Novel use of a dual-lumen single cannula bypassing RV in a VA ECMO configuration for intraoperative hemodynamic support of a patient with severe pulmonary hypertension & right ventricular dysfunction undergoing bilateral LTx, avoiding risks of CPB & postoperative switch to RVAD configuration &/or VV ECMO allowing for pulmonary support & RV unload.

Budd AN, Kozarek K, Kurihara C, Bharat A, Reynolds A, Kretzer AUse of ProtekDuo as Veno-arterial and Veno-venous Extracorporeal Membrane Oxygenation During Bilateral Lung Transplantation. J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2250-2254. link

Additional venous return on VA ECMO support in patients undergoing lung transplantation: results of this study demonstrate that conventional femoral-femoral ECLS may produce suboptimal coronary oxygenation in subjects unable to tolerate one-lung ventilation. Authors suggest the creation of a small left-to-right shunt flow, using veno-arterio-venous hybrid ECLS configuration, may improve coronary & cerebral oxygenation, preventing intraoperative differential hypoxemia, and supporting both hemodynamics & gas exchange function during LTx.

Lee JG, Kim N, Narm KS, Suh JW, Hwang J, Paik HC, Yoo YC. The Effect of Additional Stepwise Venous Inflow on Differential Hypoxia of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J. 2019 Oct 23. link

Peripheral VVA ECMO draining from both cephalad jugular vein/right atrium & reinfusing in right carotid artery: effective and feasible approach to pediatric refractory septic shock? here a case series from Sabará Hospital Infantil, Brazil!

van Leeuwen Bichara GC, Furlanetto B, Gondim Teixeira L, Di Nardo M. Is peripheral venovenous-arterial ECMO a feasible alternative to central cannulation for pediatric refractory septic shock? Intensive Care Med. 2019 Nov;45(11):1658-1660. link

Cannula related complications: limb ischemia

Limb ischemia in peripheral VA ECMO: a still frequent complication, when preventive strategies are not adopted, potentially impacting on survival and long-term functional outcome, as can lead to compartment syndrome, requiring fasciotomy or even limb amputation. Peripheral cannulation can be quickly, percutaneously established, and is less likely to cause bleeding or infections than central cannulation, but is characterized by a higher rate of vascular complications. In this paper, a comprehensive narrative review with a proposed flow chart for managing lower limb ischemia. Pathophysiology and risk factors: a multifactorial genesis that can act at any stage of the run; how to early detect: clinical signs & diagnostic/monitoring tools; preventive strategies: cannula size/side selection, cannulation technique, bidirectional cannula & distal perfusion; ECLS weaning and decannulation; treatment: threatened vs nonviable extremity? could be rather subjective (appearance of soft tissue/amount of necrotic tissue), but longer the symptoms, less likely limb salvage.

Bonicolini E, Martucci G, Simons J, Raffa GM, Spina C, Coco VL, Arcadipane A, Pilato M, Lorusso R. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment. Crit Care. 2019 Jul 30;23(1):266. Open access link

Not to miss complication on peripheral veno-arterial ECMO support: clot formation between arterial femoral cannula & reperfusion SF artery catheter detected by ultrasound in a patient with no full anticoagulation due to high bleeding risk… remember to scan all vessels with ultrasound before decannulation to prevent embolism and acute lower limb ischemia.

Au SY, Chan KS, Fong KM, Ng GWY. Clot formation between the ECMO catheter and the reperfusion catheter in a patient supported by peripheral VA-ECMO. Intensive Care Med. 2019 Nov;45(11):1657. Open access link

Percutaneous VA ECMO: cannula size & indication setting are most important factors for development of ischemic vascular complications a frequent phenomenon on ECLS with ECPR & smaller catheter associated with decreased risk in this retrospective analysis.

Lunz D, Philipp A, Müller T, Pfister K, Foltan M, Rupprecht L, Schmid C, Lubnow M, Graf B, Sinner B. Ischemia-related vascular complications of percutaneously initiated venoarterial extracorporeal membrane oxygenation: Indication setting, risk factors, manifestation and outcome. J Crit Care. 2019 Aug;52:58-62. link

Should a distal perfusion cannula must always be positioned during peripheral veno-arterial ECMO support? or not?? & what about the timing? at ECLS implantation or delayed? here an interesting correspondence including a comment and the reply by the authors of the paper referred to.

Formica F, Avalli L, Sangalli F, Danial P, Combes A, Lebreton G. Should we always use the peripheral cannula for distal leg reperfusion in femoro-femoral ECMO patients? Intensive Care Med. 2019 Apr;45(4):559-560. link

PS this the link to the original article, a propensity score framework analysis comparing outcomes of percutaneous vs surgical approach for femoro-femoral VA-ECMO (published in 2018).

Danial P, Hajage D, Nguyen LS, Mastroianni C, Demondion P, Schmidt M3, Bouglé A, Amour J, Leprince P, Combes A, Lebreton G. Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study. Intensive Care Med. 2018 Dec;44(12):2153-2161. link

Critical limb ischemia & VA extracorporeal support with femoral cannulation: the absence of distal limb perfusion identified as an independent risk factor in this evaluation involving more than 300 cases. The application of DLP during peripheral veno-arterial ECMO, regardless of the implantation technique, should be considered as a mandatory approach to minimize the ischemia-induced complications and to avoid the additional morbidity in these critically ills.

Kaufeld T, Beckmann E, Ius F1, Koigeldiev N, Sommer W, Mashaqi B, Fleissner FN, Siemeni T, Puntigam JO, Kaufeld J, Haverich A, Kuehn C.
Risk factors for critical limb ischemia in patients undergoing femoral cannulation for venoarterial extracorporeal membrane oxygenation: Is distal limb perfusion a mandatory approach? Perfusion. 2019 Feb 8:267659119827231. Open access link

Cannula related complications: infections

Cannula-related infection in patients on peripheral ECMO support happens! and not rarely, according to this cohort study (17.2 CRI per 1,000 ECMO days). CRI are associated with longer hospital stay; risk factors: longer ECLS run & higher SAPS2 score; concomitant bacteremia frequent (strongly suspect & investigate in cases of positive blood culture); management of could require exploration of the surgical site.

Allou N, Lo Pinto H, Persichini R, Bouchet B, Braunberger E, Lugagne N, Belmonte O, Martinet O, Delmas B, Dangers L, Allyn J. Cannula-Related Infection in Patients Supported by Peripheral ECMO: Clinical and Microbiological Characteristics. ASAIO J. 2019 Feb;65(2):180-186. link

Cannula related complications: thrombosis

High incidence of cannula-related thrombosis post VV ECMO reported in this observational study from the University Hospital of Regensburg ICU; reduced systemic anticoagulation may enhance the risk, sustained elevation of D-dimer after decannulation may arise the suspect; routinely screen previously cannulated vessel after ECLS with doppler ultrasound to detect this complication!

Fisser C, Reichenbächer C, Müller T, Schneckenpointner R, Malfertheiner MV1, Philipp A, Foltan M, Lunz D, Zeman F, Lubnow M. Incidence and Risk Factors for Cannula-Related Venous Thrombosis After Venovenous Extracorporeal Membrane Oxygenation in Adult Patients With Acute Respiratory Failure. Crit Care Med. 2019 Apr;47(4):e332-e339. link

Cannula-associated thrombotic complications after VV ECMO support: frequency & risk factors investigated in this study, reporting data from a large cohort of patients who underwent a thoraco-abdominopelvic CT CE scan with iodinated contrast injection within 4 days after decannulation. Cannula-associated deep vein thrombosis reported as common event (71.4% of survivors), with anticoagulation recommendations seeming to have a moderate impact on thrombotic risk, & thrombocytopenia a protective effect on CaDVT. The interest in the systematic imaging of all previously cannulated vessels following veno-venous ECLS run is advocated by authors.

Parzy G, Daviet F, Persico N, Rambaud R, Scemama U, Adda M, Guervilly C, Hraiech S, Chaumoitre K, Roch A, Papazian L, Forel JM. Prevalence and Risk Factors for Thrombotic Complications Following Venovenous Extracorporeal Membrane Oxygenation: A CT Scan Study. Crit Care Med. 2019 Nov 25. link

Cannula related complications: malposition

Echo-guided bicaval dual-lumen VV ECMO cannula placement in ICU; persistent hypoxemia/low EC flow may suggest malposition: need to reposition the during the run is common. TEE could be useful to support a stepwise approach to troubleshooting persistent hypoxemia on VV ECLS, detecting cannula malposition (ie problems with depth of cannula, tip location, orientation) and to guide repositioning.

Griffee MJ, Zimmerman JM, McKellar SH, Tonna JE. Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane Oxygenation Cannula Placement in the ICU-A Retrospective Review. J Cardiothorac Vasc Anesth. 2019 Oct 18. link

Malposition of dual lumen cannula, frequent & challenging complication in neonates on extracorporeal support: in this study, a detailed performance evaluation of the malpositioned DLC using computational fluid dynamics methodology. Considerations about atrial hemodynamics and DLC performance (drainage efficiency, blood residence time, and oxygenated blood delivery) related to patient-specific configurations with interesting graphic elements explaining different scenarios.

Jamil M, Rezaeimoghaddam M, Cakmak B, Yildiz Y, Rasooli R, Pekkan K, Salihoglu E. Hemodynamics of neonatal double lumen cannula malposition. Perfusion. 2019 Oct 3:267659119874697. link

How to prevent displacement? providing proper securement… what works in securing bicaval dual-lumen ECMO cannula? Optimal methods to provide stabilization allowing ambulation and patient comfort suggested here.

Tignanelli CJ, Weinberg A, Napolitano LM. Optimal Methods to Secure Extracorporeal Membrane Oxygenation Bicaval Dual-Lumen Cannulae: What Works? ASAIO J. 2019 Aug;65(6):628-630. open access link

Interesting case reports & series

Hazardous complication related to ECMO cannulation for EISOR, extracorporeal interval support for organ retrieval in DCD… be cautious & carefully check wire/cannula position before implementing reperfusion!

Brogi E, Circelli A, Gamberini E, Russo E, Benni M, Pizzilli G, Agnoletti V. Normothermic Regional Perfusion for Controlled Donation After Circulatory Death: A Technical Complication During Normothermic Regional Perfusion. ASAIO J. 2020 Jan;66(1):e19-e21. open access link

Novel mother-and-child fluoroscopy guided technique, assembling catheters & guidewire, to assist double-lumen bicaval VV ECMO cannula repositioning with a retrograde approach through femoral vein, maintaining extracorporeal circuit integrity. A case rep with interesting images/video content.

Kahloon R, Mangi MA, Moukarbel GV. Migrated Avalon Elite Venovenous ECMO Cannula: Novel Technique to Reposition Without Disrupting the Circuit. JACC Cardiovasc Interv. 2019 Sep 23;12(18):e161-e162. link

Repositioning a misplaced dual-lumen bicaval cannula in a 20-week-old infant on veno-venous extracorporeal support by interventional catheter technique with trans-femoral approach, using a goose neck snare & guiding the tip back into IVC, without interrupting ECMO support.

Houmesa RJ, Krasemannb T, Keyzer-Dekkerc CMG. Reposition of a Bi-caval Dual Lumen ECMO cannula using a trans-femoral lasso. Journal of Pediatric Surgery Case Reports Volume 52, January 2020. open access link

Bilateral cerebral infarction during veno-arterial #ECMO support with right carotid artery cannulation, due to rare anomaly of the circle of Willis in 6-month-old infant.

Sonobe A, Kato H, Mathis BJ, Hiramatsu Y.Catastrophic cerebral infarction during extracorporeal life support due to a rare anomaly in the circle of Willis. Interact Cardiovasc Thorac Surg. 2019 Nov 1;29(5):816-817. open access link

Novel surgical technique for minimally invasive central veno-arterial ECLS avoiding resternotomy or ventricular compression, while maintaining antegrade blood flow and permitting sternal closure following ascending aortic surgery: description & two cases of patients undergoing elective aortic arch replacement, with no short/long-term related complication.

Lorusso R, Bidar E, Natour E, Heuts S. Minimally invasive management of central ECMO after ascending aortic surgery. J Card Surg. 2019 Mar;34(3):131-133. link

Off-label use of carotid ECLS return cannula in neonates & infants < 5 kg on veno-arterial ECMO for angiography & interventions (through Y-connector with hemostatic valve) avoiding need for additional access, interesting case reports with circuit pics/clip.

Kang SL, Lee KJ, Stanisic A, Chaturvedi RR. Using the arterial cannula for cardiac catheterization in neonates and small infants supported by extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg. 2019 Apr 25. link

A case of azygous vein cannulation & drainage insufficiency at VA ECMO support implementation in a neonate, missed on chest radiography but promptly recognized & corrected with TTE: a case rep suggesting to routinely use echocardiography to guide cervical ECLS cannulation.

Runkel BG, Fraser JD, Daniel JM, Carlson KM. Identification of Inadvertent Azygous Vein Cannulation Using Transthoracic Echocardiography During Venoarterial Extracorporeal Membrane Oxygenation Initiation. CASE (Phila). 2019 Apr; 3(2): 67–70. open access link

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