Commonly, vascular access for veno-venous extracorporeal membrane oxygenation (VV-ECMO) in adult patients with acute respiratory distress syndrome (ARDS) requires cannulation of jugular and femoral veins using the Seldinger technique.1 Guide wire and cannula position is usually confirmed by radiography. Recently, a dual-lumen catheter, the Avalon Elite Bicaval Dual-Lumen Catheter (DLC; Avalon Laboratories, CA) was approved for VV-ECMO (Figure 1).2 The advantages of dual-lumen jugular vein VV-ECMO include single vessel placement, minimal recirculation, and the potential of patient ambulation.2 However, as drainage and reinfusion are realized within one cannula, guide wire and cannula placement demands sophisticated visualization with fluoroscopy or ultrasound. Usually, radiography is used for cannula depth confirmation after placement to avoid the need for repositioning during ECMO operation.3 Ideally, the visualization technique should simultaneously provide position validation and functional testing during catheter placement. In this study, we present the first application of a technique meeting these requirements by combining transesophageal echocardiography (TEE) with saline injection for performance testing.4
A 55-year-old woman was admitted on day 1 after surgical treatment for necrotizing fasciitis of the right thigh and groin in a primary care hospital. Her medical history included venous ulcus cruris of the right lower leg and extreme obesity (body mass index, 66). On admission, she was ventilated and sedated and underwent immediate necrosectomy of groin and thigh skin and subcutaneous fat. During the surgical procedure, the patient's condition deteriorated requiring the administration of 0.29 μg/kg/min norepinephrine, 0.03 U/kg/h vasopressin, and 0.10 μg/kg/min adrenaline along with 2,000 ml crystalloids and massive transfusion. Initial antibiotic therapy consisted of clindamycin, linezolid, meropenem, and penicillin. Postoperatively, the patient developed acute renal and liver failure. The next day, surgical reexploration showed clean wound conditions and cardiovascular function stabilized. Liver function recovered, while the patient still required continuous VV hemofiltration. Unfortunately, the patient developed ARDS with progressing respiratory acidosis until postoperative day 2 (Table 1), and the decision was made to establish VV-ECMO by a DLC. We considered that ultrasound visualization of microbubbles present in a saline jet from the DLC reinfusion lumen would enable optimal placement of the reinfusion opening in reference to the tricuspid valve.
After insertion of a TEE tube the right internal jugular vein was punctured with a needle. After venous position confirmation by intravascular pressure measurement, the guide wire was advanced under TEE control until positioned within the right atrium. At this stage, the guide wire “J” was turned laterally and further advanced into the inferior vena cava (IVC; Figure 2, A and B). The reinfusion lumen of a 31-French DLC was connected to a 50-ml bladder syringe filled with saline, flushed, and clamped. After serial tract dilatation, the cannula was positioned over the wire into the inferior vena cava under TEE guidance (Figure 2C). Thereafter, the cannula reinfusion lumen was declamped, and saline was injected repeatedly in 20 ml boluses through the reinfusion lumen. Thereby, the cannula position was modified until the saline jet identified by echocardiographically visible microbubbles was directed toward the right atrium and ventricle (Figure 2, D–F). Then, the cannula was secured and connected to the saline primed ECMO circuit (PLS Bioline Coating, Quadrox D Oxygenator, Maquet Cardiopulmonary AG, Hirrlingen, Germany). In Figure 2, G and H, the saline reinfusion jet from the reinfusion lumen during the initial startup of ECMO is shown. No further corrections of the cannula position were necessary during treatment. With intermittent prone positioning, lung function improved with successful assisted spontaneous breathing on day 3 after VV-ECMO. However, after day 7, recurring septic shock was uncontrollable, and the patient eventually died on day 9 from a second episode of liver failure.
This is the first description of a method, using TEE together with microbubbles present in saline for DLC VV-ECMO placement visualization in a patient with extreme obesity. Thereby, the intravascular position of the DLC was verified, and even more important, the direction of the reinfusion jet toward the tricuspid valve and right ventricle was simulated before ECMO commissioning making further corrective action unnecessary and minimizing recirculation.
Most commonly, simultaneous cannulation of the jugular and femoral veins is used for VV-ECMO. Guide wire positioning is usually confirmed radiographically before cannulae insertion. In case of DLC VV-ECMO, guide wire placement is normally confirmed by fluoroscopy or ultrasonic guidance, and DLC placement is verified either by ultrasound or roentgenogram.3,5 Actually, the first report on the use of DLC VV-ECMO in a series of 11 patients with respiratory failure reported two nonfatal cannulae displacements (right atrium and hepatic vein). In this report, transthoracic and transabdominal ultrasonic guidance allowed rapid guide wire and DLC position confirmation within the IVC. However, the exact depth of the DLC within the IVC was not exactly assessable, necessitating roentgenogram position confirmation before DLC securing and VV-ECMO commissioning, which caused a further delay until VV-ECMO initiation.3 The TEE technique described in our patient provides both DLC placement confirmation within the IVC and dynamic information about the direction of the reinfusion jet toward the tricuspid valve and right ventricle enabling optimal DLC positioning. Furthermore, TEE imaging quality remains unaffected by body mass index in contrast to fluoroscopy and avoided transportation and repositioning of our obese patient onto a radiolucent table for fluoroscopy.
In conclusion, we were able to demonstrate a new TEE-guided method for DLC placement for VV-ECMO providing simultaneous confirmation of position and function, therefore increasing patient safety.
1. Peek GJ, Mugford M, Tiruvoipati R, et al
: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet
374: 1351–1363, 2009.
2. Wang D, Zhou X, Liu X, et al
: Wang-Zwische double lumen cannula-toward a percutaneous and ambulatory paracorporeal artificial lung. ASAIO J
54: 606–611, 2008.
3. Bermudez CA, Rocha RV, Sappington PL, et al
: Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults. Ann Thorac Surg
90: 991–995, 2010.
4. Goldberg SJ, Valdes-Cruz LM, Feldman L, et al
: Range gated Doppler ultrasound detection of contrast echographic microbubbles for cardiac and great vessel blood flow patterns. Am Heart J
101: 793–796, 1981.
5. Garcia JP, Iacono A, Kon ZN, Griffith BP: Ambulatory extracorporeal membrane oxygenation: A new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg
139: e137–e139, 2010.