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ECMO Cannulation Technical Considerations Bradford Ledzian, PAC, MHS, DFAAPA, FAPACVS
ECMO Cannulation Technical Considerations
Bradford Ledzian, PAC, MHS, DFAAPA,
FAPACVS
Considerations
• Peripheral ECMO
• Central ECMO
Peripheral Approach
Peripheral Cannulation Sites
• Femoral
– Vein & Artery
• Neck
– Vein
• Axillary
– Vein & Artery
Femoral Cannulation
Femoral Cannulation
• Order of Access
• Access Ergonomics
• Location of Puncture
• Ultrasound Technique
• Incision & Dilation Technique
• Extremity Selection
• Cannula Selection
• Internal Positioning & External Securing
Femoral Order of Access
Order of Femoral Access
• Emergent
– Venous 1st, Arterial 2nd
– Antegrade Arterial Perfusion
• Controlled
– Venous, Antegrade Arterial Perfusion, Arterial
Order of Femoral Access
Femoral Access Ergonomics
Femoral Arterial Access Ergonomics
• Straight Line Principle
– PA > Operative Site > US Screen
• Fulcrum Effect
• Visual Axis
• Motor Axis
• CoAxial Alignment
Fulcrum Effect
• Left/Right external needle movement =
Right/Left internal needle movement
• Up/Down external needle movement =
Down/Up internal needle movement
Visual Axis
• PA line of vision(Eyes) > Operative site > US
image of operative site
Visual Axis
Motor Axis• PA operative manipulation(Hands) > Operative site fulcrum > Translate
action of US image
Optimal Co-Axial Alignment
Set yourself up for…
…1 stick
…1 pass
…1 puncture
Optimal Co-Axial Alignment
• VENOUS Access
– PA L foot of bed, US Right head of bed
– Right hand US, Left hand needle
Optimal Co-Axial Alignment
• ANTEGRADE ARTERIAL SFA
Access
– PA L head of bed, US Right foot of bed
– Right hand needle, Left hand US
Optimal Co-Axial Alignment
• ARTERIAL Access
– PA L foot of bed, US Right head of bed
– Right hand US, Left hand needle
Femoral Location of Puncture
Location of Puncture Puncture
• Venous
– Above GSV insertion
• Antegrade Arterial Perfusion
– Below DFA/SFA branching in SFA
• Arterial
– Above DFA/SFA branching in CFA
Location of Puncture Puncture
Location of Puncture Puncture
• Right Femoral
Location of Puncture Puncture
• Right Femoral
Location of Puncture Puncture
• Right Femoral Ideal Wire Placement
Location of Puncture Puncture
• Left Femoral
Location of Puncture Puncture
• Left Femoral
External Location of Puncture
US Technique
US Technique
• Skin contour depression deformity
• Intradermal wire tracking
US Technique
US Technique
US Technique• Geometric limitations
– Angle of Insertion
US Technique
• Trigonometric Relationships
Angle of Insertion Depth of Vascular Structure
Distance from US Probe to Stick Site
Minimum Catheter Length
45 1cm 1cm 1.4cm
45 5cm 5.0cm 7.1cm
30 1cm 1.7cm 2.0cm
30 5cm 8.7cm 10cm
Incision & Dilation Technique
Incision & Dilation Technique
• Incision length
– C = πD
– ½ C = (πD)/2
• D < Incision Length < ½C
• NonElastic Skin Elastic Skin
Incision & Dilation Technique
• Z Tracking
– Too shallow angle of dilator advancement
Femoral Extremity Cannulation Selection
Extremity Cannulation Selection
• Venous
– R leg preference
• Arterial
– Separate A/V leg preference
– Non-dominant leg preference
Extremity Cannulation Selection
Extremity Cannulation Selection
Cannula Selection
Cannula Selection Principles
• Systemic flow is indexed to BSA
– 2.2 – 2.4L/min/m2 (50-65 ml/Kg)
– BSA x Systemic Flow needs = L/min flow
• Pressures
– Venous < -100 (-130 to -150 Max)
– Internal < 350
– Arterial < 300
• Catheter Flow Characteristic
Cannula Selection
• Venous
• Arterial
• Antegrade Arterial Perfusion
Cannula Selection
• Venous (Drainage)
– 22 or 25 f
Cannula Selection
• Venous (Return)
– 23, 25, 27 f
Cannula Selection
• Arterial
– 17, 19, 21 f
Cannula Selection
• Antegrade Arterial Perfusion
• 5-9 F, 11-24cm
Femoral Internal Positioning
Internal Positioning
• Thoraco-Abdominal-Pelvic Fluoroscopy
• SFA Arteriogram
Internal Positioning
Internal Positioning
External Securing
External Securing
• Cannula Securing
– Suture
• 2 point
• Skin friction utilization
– Adhesive
• Ioban strip
• Stat-lock
– Zip-Tie
• Hemostasis/Planned closure
– Purse string
– Tourniquet buttons
External Securing
• Surgical Relevant Geometry
Femoral Cannulation
• Video Demonstration
Neck Cannulation
Cannula Selection
• Bi-Directional
Internal Jugular Cannulation
• Avelon Venous
– Thoracic Fluoroscopy
• Placement
– Passing IVC Troubleshooting
– Wire Management
• Positioning
• Cannula technique without heparin
– Transesophageal Echocardiography
• BiCaval View
Dilators
Internal Jugular Cannulation
Room SetUp
• Wire Management Technique
Internal Jugular Cannulation
• Optimal Co-Axial Alignment
Internal Jugular Cannulation
Internal Jugular Cannulation
• IJ approaches• Central
• Insertion at bifurcation of SCM directed straight
• Posterior• Insertion lateral to clavicular
head of SCM directed medial
• Anterior• Insertion medial to sternal
head of SCM and directed lateral
Location of Puncture Access
Location of Puncture Access
Axillary Cannulation
Axillary Cannulation Arterial
• US Imagable
• Arm Positioning
• Cutdown
• Flow Restriction
Axillary Vascular Cannulation
• Optimal Co-Axial Alignment
Axillary Cannulation Venous
• US Imageable
• Compressable
• NOT Subclavian
Location of Puncture Access
• Left Axillary InfraClavicular Fossa
Location of Puncture Access
• Arm Tucked vs Arm Right Angle
VV Considerations
VV Consideration
• Cannulation options
– R IJ VV duel lumen
– Fem-Fem
– Fem-IJ
– Fem-Axillary
VV Consideration
VV Consideration
• Recirculation
– Recirculation = (SpreOx – SvO2)/(SpostOx-Svo2)
– Effective Flow = Total Flow - (Total Flow *
Recirculation Fraction)
• Contributing Factors
– Pump Flow
– Catheter Position
– Cardiac Output
– RA Size
VV Consideration
VA Considerations
VA Consideration
• Harlequin Syndrome/North-South Syndrome
– R Radial A-Line
– TEE Mixing Imaging
– V-AV
VA Consideration
• LV Stasis/Thrombous
– LV Venting Options
VA Considerations
Central Cannulation
Central Cannulation
• Tunneling issues
Central Cannulation
Central Cannulation
Conclusion for now…
Thank you
