Disclosures Definition Cannulation Strategy Cannulation Strategy

Cannulation Strategies for
Extracorporeal Membrane
Oxygenation (ECMO)
Michael H. Hines MD, FACS
Professor of Pediatric Surgery, CV
Professor of CV Surgery
The University of Texas Medical School at Houston
ECMO Director CMHH and MHH
Definition
•ECMO for temporary, “long-term” support
of cardiac and/or pulmonary function in
order to bridge to recovery, bridge to
decision, or bridge to other forms of
support and/or transplant.
•NOT VAD’s, Impella, CPB…
Cannulation Strategy
• Define Needs and Goals of support
• Review access options for that support
• Assess benefits / risks of those options
• Have plan to deal with complications
Disclosures
* No Financial Disclosures
* All equipment discussed is FDA approved
for use in extracorporeal support
Cannulation Strategy
• Define Needs and Goals of support
• Review access options for that support
• Assess benefits / risks of those options
• Have plan to deal with complications
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General Goals
• Maximum drainage without complications
of venous obstruction
• Unobstructed inflow without distal
ischemia
• Lowest risk of infection
• Mobilization of the patient when possible
Cannulation Strategy
• Define Needs and Goals of support
• Review access options for that support
• Assess benefits / risks of those options
• Have plan to deal with complications
Goals & Needs
• Cardiac Failure – Need VA
• Respiratory Failure – Use VV
– Options – DL and Two cannula
• Combined Cardio-respiratory
– “proximal” VA or VA/V
Cannula options
• MANY BRANDS, TYPES
• Sizes up to 28 French V, for peripheral
• Wire-reinforced to prevent collapse, kink,
(Non OK for inflow)
• Seldinger options? Kits?
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Arterial options
• Femoral artery
• Axillary artery
• Carotid Artery
• Aorta
Venous options
• Femoral vein (Intrahepatic IVC)
• Subclavian Vein
• Internal Jugular Vein
• Right Atrium
Arterial options
• How much flow do I need?
• Can I get to it?
• Is it diseased?
• Can I stick it or do I need to cut-down?
• Do I need a graft?
Venous options
• How much flow do I need?
• Can I get to it?
• Is it clotted (DVT)? Or is it injured?
• Can I stick it or do I need a cut-down?
Cannulation options
• Percutaneous Seldinger
– All venous, femoral arterial
• Cut-down with Seldinger
– Venous ECPR, Carotid, Femoral (Purse-string)
?Axillary – usually graft
• Cut-down with end-to-side graft
– Axillary, at risk carotid, diseased femoral
• Transthoracic (FTW, High C.O. sepsis)
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Cannulation options
• Fluoroscopy (contrast)
• Echocardiography
• Vascular Ultrasound
• Radiographs
• MUST KNOW CAPABILITIES and
LIMITATIONS of EACH
Cannulation Strategy
• Define Needs and Goals of support
• Review access options for that support
• Assess benefits / risks of those options
• Have plan to deal with complications
Venous options
• Femoral vein (Intrahepatic IVC)
– Perc / Leg edema, Infection, Immobilization
• Subclavian Vein
– Perc / Size, Arm edema
• Internal Jugular Vein
– Perc, RA flow, DL option/ (SVC syndrome?)
• Right Atrium
– Great flow / Sternotomy, open chest, infection
Cannulation Strategy
• Define Needs and Goals of support
• Review access options for that support
• Assess benefits / risks of those options
• Have plan to deal with complications
Arterial options
• Femoral artery
– Perc / Retrograde, Leg ischemia, Infection
• Axillary artery
– Good flow, less CVA / Graft, Arm overcirculation
• Carotid Artery
– Good flow / Cutdown, ?Ligation, CVA
• Aorta
– Great flow / Sternotomy, infection
Risks / Solutions - Arterial
• CVA (Avoid carotid, or use graft)
– Avoid carotid, or move ASAP (Repair?)
– Caution with diseased aorta
– Caution with femoral retrograde flow
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Risks / Solutions - Arterial
• CVA (Avoid carotid, or use graft)
– Avoid carotid, or move ASAP (Repair?)
– Caution with diseased aorta
– Caution with femoral retrograde flow
• Atherosclerosis & Distal ischemia
– Antegrade cannula
– Retrograde (DP, PT) line
– Contralateral graft
• Open Chest (Can tunnel and close)
• Intra-abdominal
IVC is soft, pliable
and collapsible
Risks / Solutions - Arterial
• CVA (Avoid carotid, or use graft)
– Avoid carotid, or move ASAP (Repair?)
– Caution with diseased aorta
– Caution with femoral retrograde flow
• Atherosclerosis & Distal ischemia
– Antegrade cannula
– Retrograde (DP, PT) line
– Contralateral graft
Risks / Solutions - Venous
• Venous Occlusion
– Rare, but don’t occlude BOTH IJ’s
– Anticoagulation probably helps
• Recirculation (VV ECMO)
– Drain from below, infuse into RA (IJ e.g.)
• Venous “chatter”
– RA or Intrahepatic IVC, NOT intra-abdominal
• Intrahepatic IVC
will not collapse
and chatter.
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Risks / Solutions - Venous
• Venous Occlusion
– Rare, but don’t occlude BOTH IJ’s
– Anticoagulation probably helps
• Recirculation (VV ECMO)
– Drain from below, infuse into RA (IJ e.g.)
• Venous “chatter”
– RA or Intrahepatic IVC, NOT intra-abdominal
• Occlusion - Accessory drainage?
Special Circumstances
• LV Venting (VA ECMO)
– PV, LA appendage (open sternotomy)
– LV apex (mini L Thoracotomy)
– PA
– Atrial septostomy
• Femoral VA for respiratory Failure – VA-V
• VA ECMO with
Fem-Fem
approach
• Reasonable for
Cardiac
Resuscitation
BUT
• POOR for
Respiratory
Failure
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• Oxygenated
Blood up Fem
will likely not
get up into arch
if LV is
ejecting
• VA for arrest,
hemodynamic
• Support Heart
with Fem Fem
VA
• Support Lungs
with addition of
VV limb
• “VA-V
ECMO”
Other principles & Pearls…
• Venous occlusion RARELY a problem…
• Limitation to flow usually venous drainage,
NOT arterial line pressure…
• Commonly TOO SMALL, or TOO LOW…
• Over-insert venous (can always pull back)
• NEVER need an A-cannula as big as V…
• In emergency, use percutaneous
• CAN cannulate under local !!
• Every problem has a potential solution !!
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