Extracorporeal membrane oxygenation (ECMO) is used in patients with severe pulmonary or cardiac failure. In patients with primary respiratory failure and relatively preserved cardiac function, venovenous ECMO can support the gas exchange function normally performed by the human lung by drawing deoxygenated blood from the venous system and returning it directly to the right atrium after oxygenating it via an extracorporeal gas exchange device.1 There are two commonly used configurations of venovenous ECMO: single-site cannulation of the right internal jugular (RIJ) vein and two-site cannulation typically involving the internal jugular and femoral veins. Single-site cannulation has been used at our institution since the development of the Avalon Elite Bicaval Dual-Lumen catheter (Avalon Laboratories, LLC, Rancho Dominguez, CA). With this dual-lumen catheter, one lumen drains deoxygenated blood from the superior vena cava (SVC) and inferior vena cava (IVC), while the other lumen returns oxygenated blood to the right atrium. This approach allows for single-site access, which has several advantages. A single catheter in the internal jugular vein facilitates patient participation in physical therapy, preserves the femoral vein as another potential venous access site, and minimizes the number of potential sites of infection. Single-site cannulation also minimizes the potential for recirculation of blood flow, in which a portion of the oxygenated blood being reinfused from the ECMO circuit is drawn back into the circuit and not systemically circulated.1,2 The bicaval dual-lumen catheter has traditionally been placed via the RIJ vein given the direct course the catheter takes through to the IVC. However, in patients in whom the RIJ insertion site is inaccessible, single-site cannulation is generally not considered. We report our experience with four patients in whom the bicaval dual-lumen catheter was successfully inserted via the left internal jugular vein (LIJ), with adequate blood flow and gas exchange in each case.
The indications for initiation of venovenous ECMO in the four cases were hypoxemic or hypercapnic respiratory failure (Table 1). Two cases involved patients with severe acute respiratory distress syndrome, in which ECMO was used as a bridge to lung recovery. The other two patients had severe exacerbations of cystic fibrosis (CF) complicated by hypercapnic respiratory failure and were being bridged to lung transplantation. In each of the patients with CF, there was a history of chronic indwelling central venous catheters.
In case I, our surgical team placed the patient on venovenous ECMO at an outside institution before transfer. The RIJ vein was accessed using standard Seldinger technique, but the guidewire could not pass despite several attempts. The site was abandoned after a hematoma developed at the insertion site, and the RIJ vein could no longer be used. The LIJ was subsequently approached, with successful placement of a 23 Fr dual-lumen catheter, with the position confirmed using fluoroscopy (Figure 1). After initiation of venovenous ECMO, the patient was transferred to our hospital with the left-sided catheter in place without any complications during transport or thereafter. In case II, the RIJ vein was visualized with ultrasound and was noted to be markedly stenotic, precluding catheter placement from that side. Ultrasound showed the LIJ to be of sufficient caliber for the catheter to be inserted. A 23 Fr dual-lumen catheter was successfully placed via the LIJ using fluoroscopy to confirm guidewire placement and transesophageal echocardiography (TEE) to confirm that the reinfusion flow was directed toward the tricuspid valve. In case III, access was initially attempted via the RIJ vein, however, despite adequate venous return, the guidewire was unable to pass through a stenotic region just proximal to the confluence of the right brachiocephalic vein and the SVC. The LIJ was then accessed, with confirmation of guidewire placement by fluoroscopy, and a 23 Fr dual-lumen catheter was easily advanced. Placement of the catheter was confirmed with fluoroscopy and TEE. In case IV, which was also done at an outside hospital, the RIJ vein was found to be thrombosed from prior catheterization, and the decision was made to cannulate the LIJ. A standard Seldinger approach was used to insert a 27 Fr cannula into the LIJ under TEE guidance alone. In our experience, only 23 Fr or 27 Fr catheters were used. A 31 Fr dual-lumen catheter might be required in some patients depending on the physiologic needs and anatomy of the patient. The safety of placing such a catheter in the LIJ is unknown.
The surgical approach for placement of the bicaval dual-lumen catheter in the LIJ is similar to that previously described by our team for the RIJ approach.3 The LIJ is accessed percutaneously with a Seldinger needle. The guidewire is advanced into the IVC using fluoroscopy or TEE. In our case series, fluoroscopy was used to confirm guidewire placement in all but case IV, in which TEE was used because the patient was too unstable to transport to a location with fluoroscopy. Serial dilation was completed with a standard cannula dilator kit. In our case series, we used either a 23 Fr or a 27 Fr catheter. The critical step is TEE confirmation that the outflow port was in the right atrium, and the oxygenated reinfusion blood flow was oriented toward the tricuspid valve. The proximal and distal inflow ports were positioned in the SVC and IVC, respectively. Incorrect orientation of either the drainage or reinfusion ports may lead to inadequate blood flow or recirculation. There were no instances of facial or cerebral edema, likely because one of the inflow ports is positioned in the SVC.
This case series demonstrates the feasibility of using the LIJ approach for placement of the bicaval dual-lumen catheter for the initiation and maintenance of venovenous ECMO, while providing adequate blood flow and gas exchange. The procedure is similar to that used with the RIJ approach. As with all cannulation procedures, there is a risk of perforation of the venous system or even the right heart, especially because the left-sided approach involves more angulations through the venous system. The procedure should be performed by a clinician with expertise in placement of these cannulae, and we recommend confirmation of guidewire and catheter placement via fluoroscopy and TEE, both of which can be done at the bedside with the right equipment.3 All bicaval dual-lumen cannulae from 20 to 31 Fr have the same length (31 cm). Selection of cannula size is determined by the amount of flow that we estimate the patient will need based on body size, estimated cardiac output, and physiologic needs. There was no difficulty in ensuring cannula placement in the IVC in any of these patients, despite significant variation in patient height. We did not experience any issues with dislodgement, however, it is possible that the increased length of travel from the LIJ may make the cannula more susceptible to dislodgement. Although this is a series of only four cases, our success with this approach has significant clinical implications because it demonstrates the feasibility of an alternative cannulation site when the RIJ site is not available for the placement of a bicaval dual-lumen catheter. This is particularly important in patients in whom the RIJ vein is inaccessible because of anatomic restrictions, such as stenosis from prior long-term insertion of central venous catheters (e.g., chronic intravenous therapy for patient with CF) or from hematomas from prior unsuccessful right-sided attempts at venous access. More cases are needed to confirm the safety and feasibility with cannulae of different sizes.
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