Until the early 1980s, cannulation for cardiopulmonary bypass (CPB) was routinely done through intrathoracic access, typically requiring a sternotomy. More recently, percutaneous cannulation for CPB has become more common because it provides a controlled setting for reoperative sternotomies and facilitates minimally invasive cardiothoracic surgeries.1,2 Typically, the femoral vessels are cannulated because of their ease of access and large vessel caliber, which enables adequate flow.3 Femoral cannulation has its limitations, including reduced upper extremity and cerebral oxygen delivery. Furthermore, for prolonged femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO), patients may require antegrade perfusion catheter inserted into the superior femoral artery. Other configurations of access have been described, especially in patients with iliofemoral disease. Large vessels such as the internal jugular vein, the carotid artery, and the axillary artery with a side graft have been used for peripheral cannulation.1,4 In adult patients, the carotid artery is avoided because of the associated ischemic and neurologic side effects.
The Adult ECMO program at Columbia University Medical Center has used the Avalon Elite Bicaval Dual Lumen catheter (Avalon Laboratories, LLC, CA) since its Food and Drug Administration approval in early 2009 in 28 patients requiring venovenous (VV) ECMO. This catheter, conceptualized by Wang and Zwischenberger, provides not only the drainage of deoxygenated blood, but also the reinfusion of oxygenated blood with minimal recirculation via a single internal jugular access.5 All patients achieved appropriate flows and gas exchange without recirculation problems. We have adapted the Avalon Elite catheter to serve additional functions: full CPB and conversion to VA ECMO. In this report, we describe how the catheter was modified into a high-flow, single venous outflow for use in CPB and VA ECMO. Both patients were able to avoid the need for extra venous cannulation by using the existing Avalon Elite catheters.
A 50-year-old women with end-stage cystic fibrosis was admitted to the hospital for hypercarbic and hypoxemic respiratory failure. Despite aggressive medical management, her respiratory status worsened, and she required mechanical ventilation. After failing mechanical ventilatory support, VV ECMO was initiated via a 27-Fr Avalon Elite catheter in the right internal jugular vein. The patient's oxygenation status improved considerably, and the following day, she was extubated while on ECMO. After 18 days of bridging ECMO support, the patient underwent a double lung transplant. Because of hemodynamic compromise and elevated pulmonary artery pressures, CPB was instituted during the procedure. The existing Avalon Elite catheter was used for full venous drainage by connecting the two end ports to a Y-connector and attaching it to the venous drainage of the CPB circuit (Figure 1). The aorta was cannulated centrally with a Sarns 7.0-Fr Soft-Flow cannula (Terumo, Ann Arbor, MI). Full CPB was achieved with flows ranging from 3.8 to 4.0 L/min. After the lung transplant, the patient required ECMO for primary graft failure, and the Avalon catheter was readapted for VV ECMO. Ultimately, the patient recovered and lives independently.
A 64-year-old man with multiple comorbidities underwent a reoperative aortic valve and root replacement. His postoperative course was complicated by pulmonary hypertension and cardiogenic shock requiring an intra-aortic balloon pump and respiratory failure requiring VV ECMO support via the 27-Fr Avalon Elite catheter. Despite these measures, the patient's pulmonary artery pressures remained elevated and the cardiogenic shock did not improve. The decision was made to convert from VV to VA ECMO. As in the previous case, the end ports of the Avalon catheter were connected to a Y-connector to provide venous drainage (Figure 2). The right axillary artery was cannulated by first anastomosing an 8-mm Hemashield graft (Boston Scientific, Natick, MA) onto the artery and inserting a tunneled 24-Fr EOPA CAP cannula (Medtronic, Minneapolis, MN) into the graft. This configuration reached flows of 5.4 L/min and provided full cardiopulmonary support for the patient.
The patient's hemodynamic and physiologic condition improved immediately as evidenced by weaning his vasopressors off within 6 hours of VA ECMO. Unfortunately, the patient suffered an anoxic brain injury during the earlier phase of his cardiogenic shock and care was withdrawn. We have used this configuration in other cases and have achieved flows as high as 7.7 L/min with a 31-Fr catheter (5.0 L/min from the caval ports and 2.7 L/min from the atrial infusion port).
The Avalon Elite Bicaval Dual Lumen catheter was designed for percutaneous placement into the right internal jugular vein for VV ECMO. One lumen drains the vena cava through a distal opening in the inferior vena cava (IVC) and proximal ports in the superior vena cava (SVC). The second lumen infuses oxygenated blood into the right atrium (RA) and across the tricuspid valve. An inner membrane serves to separate the drainage and infusion flows.5 Recirculation can be a problem with VV ECMO circuits.6,7 The Avalon Elite minimizes this problem by directing oxygenated flow into the right heart. To ensure correct placement and maximum performance, the catheter is inserted using the Seldinger technique under either fluoroscopic or transesophageal echocardiographic (TEE) guidance. In the first case, we used both techniques to confirm placement. In the second case, we relied on TEE, which allows assessment of both positioning and outflow. Once correct placement is confirmed, it is connected to the ECMO circuit. We consistently use one or both guidance techniques for inserting this cannula. Early on, there was one instance of SVC injury during dilation, which was immediately diagnosed and repaired. Based on this example and other anecdotal evidence of insertion-related complications, insertion of this dual lumen catheter may be challenging for the novice. We recommend the TEE-only approach for the experienced operator.
For patients on VV ECMO via the Avalon catheter, a conversion to CPB or VA ECMO can be accomplished by adapting the existing catheter, thus avoiding peripheral or central cannula changes. Instead of using one lumen for inflow and the other for outflow, the two lumens are connected using a Y-connector. The end of the Y-connector is then joined to the venous drainage of the extracorporeal or CPB circuit. The three drainage openings of the catheter provide a generous return of blood from the SVC, IVC, and RA. The infusion ports in 27- and 31-Fr Avalon Elite catheters accommodate a flow probe and negative pressures. In this configuration, a probe placed on the soft, collapsible inflow lumen confirmed that it stayed open under pressures of −50 mm Hg and sustained 2.7 L of flow. We suspect that smaller cannulae (23 Fr or less) may not provide significant drainage.
To complete the circuit, the arterial cannula can be placed intrathoracically or peripherally. By doing so, a patient who is on VV ECMO using the Avalon catheter can be converted to CPB or VA ECMO by adding one arterial cannula instead of replacing the existing catheter or placing multiple cannulae. Using a combined axillary artery cannulation and the Avalon Elite venous cannulation will also facilitate mobilization and ambulation in patients on VA ECMO.
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