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Vascular Access &

Cannulation

Dr Osama Bawazir Assistant Professor  , Consultant Pediatric surgeon

FRCSI, FRCS(Ed), FRCS (glas), FRCSC,

FAAP,FACS.

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• ECMO is a supportive measure, whichcan be instituted as an urgent, semi

elective or elective procedure

• Time in relation to the event is the

limiting factor when going through the

assessment cascade in order toaccomplish a successful result

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• PRE-ECMO ASSESSMENT

• CANNULATION

• INITIATION AND MAINTENANCE OFECMO

• EVALUATION

Introduction

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CANNULATION

The establishment and

maintenance of

adequate vascularaccess is essential

for ECMO

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CANNULATION

- Patient age and size-  Underlying disease &

condition

- Cause of the cardiorespiratory

compromise

- Type of support:

 – Veno-venous (VV) ECMO

 – Veno-arterial (VA) ECMO

- Time of the event in relation to

the peri-operative period

- Location

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CANNULATION

For each modality, there aredifferent kinds and sizes of

cannulae that can be used

Target activated clotting time(ACT) should be

accomplished first before

ECMO (heparin 100 units/kg)

3 minutes before cannulation.Consent

GA

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Guidelines for Cannula size

Weight (Kg) Venous cannula arterial cannula

2-4 8-14 8-10

5-15 15-19 12-15

16-20 19-21 15-17

21-35 21-23 17-19

35-60 23 19-21

>60 23 21

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Poiseuille’s Law 

• Poiseuille's law: In anartificial system, flowthrough a cylindrical tubeor any segment of a tube isdirectly proportional to ΔP,

the driving pressure alongthe tube, and the fourthpower of the radius, r. Flowis inversely proportional toL the length of thesegment and to η, theviscosity of the liquid. Theproportionality constant isπ/8.

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Cannula Consideration

• Venous cannula should be with the largest

lumen and shortest length possible

(gravity).

• Venous cannula should have side holes.

• M-number

• Resist kinking• The smallest double lumen cannula is size

12 F ( for V V ecmo in neonate)

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CANNULATION

• Veno -Venous (V-V) ECMO  

- Mainly used for respiratory 

support (ARDS & Congenital

Diaphragmatic Hernia)

- V-V ECMO provides adequate

oxygenation and CO2

removal- The venous access can be

established by using the

system in one site, or two

different sites

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CANNULATION

• Veno -A rterial (VA)

ECMO

provides cardiac as

well as respiratory 

support and is mainlyused for post op

cardiac case

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(V-V) ECMO Advantage offer  

(V-A) ECMO 

• Eliminate the potential for arterial

embolization and ischemia

•  Arterial ligation or repair is unnecessary

• Improve the blood flow and oxygenation to

pulmonary circulation.

• No hemodynamic effects

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CANNULATION TECHNIQUE

• Open

• Semi-open• Percutaneous

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CANNULATION

Internal jugular vein

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CANNULATION

Subclavian vein &

Right atrium

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CANNULATION

Femoral vein

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CANNULATION

One site

-  A double lumen cannula isinserted into the internal jugular  vein

- Only one site for venousaccess

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CANNULATION

Two different sites

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CANNULATION

• Veno -A rterial (VA) ECMO

provides cardiac as well asrespiratory support and is

mainly used for post op

cardiac case

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CANNULATION

Internal jugular vein

and the common

carotid artery

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CANNULATION

Right atrium and

ascending aorta

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CANNULATION

Femoral vein and

artery

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CANNULATION

In situations where ECMO

support is anticipated

- Chest will be left open

and covered by a Silastic

patch

- Purse-string sutures will

be left snared in place

- Standby preprimed pump

will be kept in ICU

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CANNULATION  PROBLEMS

• Threading the venous

catheter

• Vein division

• Proximal vein lost in

mediastinum

• Lack of venous return

• Intrathoracic vein

perforation

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Complication

• Vascular injury( tear,intimal dissection,perforation).

• Obstruction (kinking,positional).

• Misplacement( AI,

afterload

 LV failure).• Bleeding.

• Recirculation.

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Thank You