Prevention and treatment of intensive care unit (ICU)-acquired weakness require early mobilization of patients in the ICU. Despite the use of life support therapies, early mobilization reduces muscle atrophy and leads to improved strength and physical function.1 Initiation of early mobility in patients receiving extracorporeal membrane oxygenation (ECMO) is challenging, in part, related to the use of femoral cannulation.2 Placement of a single Avalon Elite Bicaval dual-lumen ECMO cannula allows early mobility in patients in the ICU, requiring venovenous (VV)-ECMO for severe hypoxemia and acute respiratory failure. This issue is particularly important in patients requiring prolonged ECMO support, including the increasing number of patients on VV-ECMO as a bridge to lung transplantation.3
The Avalon bicaval cannula (Avalon Elite Bicaval Dual-Lumen Catheter and Vascular Access Kit; MAQUET Cardiopulmonary, Rastatt, Germany) is an important tool for adult VV-ECMO support and has been successfully used.4–7 One lumen provides inflow to the ECMO circuit by drainage from both the superior and the inferior vena cavae (IVC), and the other lumen provides outflow of oxygenated blood into the mid-right atrium. The advantages of the Avalon bicaval cannula include avoidance of femoral cannulation, thus allowing initiation of early mobility, decreased recirculation, and percutaneous placement of a single cannula for VV-ECMO support.
However, placement of the Avalon bicaval cannula is not without risk. In addition to the standard risks of central venous catheter placement, including pneumothorax and vascular injury, the potential for right ventricular rupture because of intracardiac migration of the guidewire during sequential dilation for Avalon cannula placement has previously been reported.8 Because of concern on this complication, our standard of care is to perform Avalon cannula placement in an imaging suite using fluoroscopy or ECMO cannulation via the internal jugular and femoral veins using separate single-lumen ECMO cannulae in the ICU in unstable patients who would not tolerate transport to a fluoroscopy room.
This report describes our specific endovascular technique for Avalon bicaval cannula placement to prevent intracardiac migration of the guidewire and facilitate precise positioning of the Avalon cannula tip in the IVC.
A 36-year-old woman (weight 72 kg, height 168 cm), with acute interstitial pneumonitis and severe hypoxemia refractory to conventional and rescue acute respiratory distress syndrome (ARDS) treatment strategies, was cannulated for VV-ECMO. Initial cannulation was via right and left femoral veins because of difficulty in gaining access to the right internal jugular vein. After 30 days of VV-ECMO support, she was taken to the operating room for placement of the Avalon bicaval cannula and removal of the femoral cannula to allow for mobilization, physical therapy, and reconditioning.
After successful percutaneous access to the right internal jugular vein using real-time ultrasound guidance, the Avalon guidewire (0.038″ × 210 cm) was advanced into the IVC under fluoroscopic guidance (Figure 1A). Advancement of the large Avalon dilators over the Avalon flexible guidewire (despite the tip of the guidewire in the right iliac vein) resulted in the guidewire retracting and looping into the heart (Figure 1B–D).
We then placed a Berenstein (angled) directional catheter over the wire, and the Avalon soft guidewire was removed. A 180 cm, 0.035″ Amplatz Super Stiff guidewire (Boston Scientific, Natick, MA) was passed through the catheter and advanced under fluoroscopic visualization into the distal IVC (Figure 2A). Serial dilation was performed up to 26 Fr, and a 27 Fr Avalon bicaval cannula was advanced without complication (Figure 2B). The wire did not migrate, and the cannula was advanced without difficulty. The cannula position in the subdiaphragmatic IVC was confirmed by fluoroscopy and chest radiograph (Figure 2C).
A 40-year-old woman (weight 69 kg, height 163 cm) with an unremarkable medical history was transferred with severe hypoxemic respiratory failure secondary to ARDS likely because of bacterial pneumonia after a 2 week course of upper respiratory symptoms thought to represent a viral upper respiratory tract infection. Left thoracoscopic lung biopsy at the referring hospital confirmed cryptogenic organizing pneumonia, but reevaluation of the pathology slides at our institution confirmed diffuse alveolar damage.
Because of severe hypoxemia and unstable hemodynamics, ECMO cannulation was performed in the ICU with cannulation via the right internal jugular (23 Fr short in mid-right atrium) and right femoral (28 Fr 68 cm long single-lumen cannula in subdiaphragmatic IVC) veins. Native lung function did not improve quickly, and we decided to transition to Avalon bicaval cannula placement for mobilization and reconditioning.
In the operating room, we first placed a short left femoral drainage cannula so that VV-ECMO support would be continued during the procedure. This allowed isolation of the right internal jugular single-lumen ECMO cannula to be exchanged to an Avalon bicaval cannula. The technique below was used, with a 3/8″ perfusion adapter, a Berenstein (angled) catheter, and an Amplatz Super Stiff guidewire (Figure 3A), facilitating placement of a 27 Fr Avalon bicaval ECMO cannula in the right internal jugular position without complication (Figure 3B).
Placement of the Avalon bicaval ECMO cannula is performed using sterile technique under fluoroscopic guidance. For adults, the Avalon 210 cm guidewire kit is used (Table 1 and Figure 4), which contains all appropriate size dilators for Avalon ECMO cannula placement. The Avalon bicaval cannula can be placed de novo (no prior right internal jugular cannulation), via central venous catheter exchange, or via single-lumen ECMO cannula exchange. Additional endovascular equipment is required for optimal safe placement of the Avalon bicaval ECMO cannula (Table 2 and Figures 5, 6, and 7), and the specific use of these endovascular supplies is detailed below in each technique.
De Novo Avalon Placement
Right internal jugular venous access is obtained with real-time ultrasound guidance using the 18g needle in the Avalon Vascular Access Kit. Venous access is confirmed using manometry. Using Seldinger technique, the Avalon guidewire (0.038″ × 210 cm) is advanced into the right atrium. A Berenstein (angled) directional catheter that accepts a 0.038″ guidewire (4 Fr [ID 0.042″] or 5 Fr [ID 0.046″], 100 cm) is advanced over the guidewire with the directional tip positioned posterolaterally, away from the right ventricle and hepatic veins, as it is advanced with fluoroscopic guidance through the right atrium into the subdiaphragmatic IVC and iliac vein. The position of the distal tip of the catheter and guidewire is confirmed fluoroscopically in the distal IVC or iliac vein.
If a Berenstein catheter of sufficient size to accept a 0.038″ guidewire is not available, or if there is difficulty encountered when advancing the Avalon 0.038″ guidewire through the Berenstein catheter, it should be exchanged for a 0.035″ floppy or stiff-angled Glidewire (hydrophilic-coated guidewire, 180 cm, 0.035″ OD; Terumo Medical Corporation, Somerset, NJ) to engage the iliac vein. The angled floppy or stiff Glidewire provides extra support, torque response, and pushability to achieve deeper vessel purchase. The guidewire is advanced as distally as possible into the iliac vein.
The Avalon soft guidewire (or Glidewire) is then exchanged for an Amplatz Super Stiff guidewire with fluoroscopic confirmation of the distal tip of the Amplatz guidewire in the distal IVC or iliac vein. The Berenstein (angled) catheter is removed, and sequential dilation using the Avalon dilators is completed. The use of slight traction on the guidewire during dilation and implantation of the ECMO cannula can assist in optimal placement. The Avalon bicaval cannula is advanced over the Amplatz guidewire and is positioned with the tip of the cannula in the subdiaphragmatic IVC and the medial lumen with the outflow port to the mid-right atrium toward the tricuspid valve. The tip should ideally lie below the level of the hepatic veins.
In adults, 23, 27, and 31 Fr Avalon bicaval dual-lumen cannulae can be used for VV-ECMO. We prefer the use of 27 and 31 Fr cannulae that allow the increased (3.5–5 L/min) flow under standard conditions and choose size based on the size of the patient, the size of the right internal jugular vein to be cannulated, and the desired flow rates.
Central Venous Catheter Exchange
If a central venous catheter is present in the right internal jugular position, a standard central line guidewire (.025″ [0.64 mm] diameter × 68 cm “J” Tip guidewire) is advanced into the vessel and the existing central line is removed. The Avalon guidewire (0.038″ × 210 cm guidewire) will not fit in a standard central venous catheter. The smallest diameter Avalon dilator (10 Fr) is advanced over the central line guidewire and exchanged for the Avalon kit guidewire (0.038″ × 210 cm guidewire). Once the Avalon guidewire is in place in the right atrium, the same procedure is performed as described above in the de novo Avalon bicaval ECMO cannula placement.
Single-Lumen ECMO Cannula Exchange
If a previous single-lumen ECMO cannula is in place in the right internal jugular position, the existing ECMO cannula is first flushed with heparinized saline after VV-ECMO is continued via a femoral-femoral approach. A 3/8″ perfusion adapter is then attached to the open end of the ECMO cannula and used to minimize blood loss from the existing ECMO cannula during the passage of the guidewire.
Using Seldinger technique, the Avalon guidewire is advanced through the 3/8″ perfusion adapter and existing ECMO cannula into the mid-right atrium. Once the guidewire position is confirmed by fluoroscopy, the existing ECMO cannula is removed, and digital pressure is required to prevent bleeding at the site. A Berenstein (angled) directional catheter that accepts a 0.038″ guidewire (4 Fr [ID 0.042″] or 5 Fr [ID 0.046″], 100 cm) is advanced over the Avalon guidewire and advanced into the iliac vein, and the guidewire is removed. The Amplatz Super Stiff guidewire is then advanced (within the Berenstein (angled) catheter to protect the vessel) into the distal IVC with fluoroscopic confirmation. The Berenstein catheter is removed, appropriate serial dilation is performed, and the Avalon cannula is inserted under fluoroscopic guidance. It is imperative to ensure that the Amplatz guidewire remains in the distal IVC or iliac vein by external stabilization of the guidewire during this entire process. Proper positioning of the Avalon cannula is confirmed and it is sutured in place. Once the cannula position is confirmed, coordination with ECMO specialists is essential for conversion from dual cannula support to Avalon single cannula bicaval dual-lumen VV-ECMO support.
Securing the Avalon Bicaval Dual-Lumen Cannula
It is important to appropriately secure the ECMO cannula so that it does not kink or twist. Two 0 silk pursestring sutures are placed at the insertion site, securing the sutures around the cannula as well. Additional individual 0 silk sutures are placed at approximately 1 to 2 cm intervals cephalad to the insertion site in the right internal jugular vein so that the ECMO cannula lies straight adjacent to the neck without kinking, with care taken to put the highest two sutures at the “y” of the double-lumen cannula (sometimes in the scalp) so that it does not twist or kink at this site. Coban self-adherent elastic wrap (3M, St. Paul, MN) is placed to further secure the cannula and tubing at the forehead. Daily chest radiographs are used to confirm appropriate position of the ECMO cannula.
The Avalon bicaval dual-lumen cannula is a very useful tool for allowing patients to participate in early mobility during prolonged VV-ECMO, in particular when used as a bridge to lung transplantation where functional rehabilitation and ambulation are essential. Optimal safe placement of the Avalon bicaval cannula is necessary, and specific endovascular methods and techniques, reviewed above, can facilitate prompt safe placement of the Avalon bicaval cannula for VV-ECMO.
It is important to recognize that the guidewire included in the Avalon Vascular Access Kit is flexible, and sequential dilation with the rigid Avalon dilators may result in inadvertent retraction and looping of the guidewire into the heart. This creates a risk of malposition or injury to the superior vena cava, right atrium, or right ventricle.
We use two common endovascular tools and techniques to facilitate safe insertion of the Avalon bicaval cannula: a directional Berenstein catheter and an Amplatz Super Stiff guidewire. The Berenstein hockey stick catheter is made of nylon and thus has a low coefficient of friction. The preformed shape, combined with good torque characteristics, makes the Berenstin catheter steerable. The Amplatz Super Stiff guidewire is more rigid and remains in position in the IVC as the dilators and Avalon cannula are advanced.9 One limitation to this approach is the potential for vessel injury because of the rigidity of the wire. For this reason, we only use this wire under fluoroscopic visualization, and the wire is only advanced while in a protective catheter.
The use of the Amplatz Super Stiff guidewire prevents the risk of intracardiac wire looping and potential cardiac perforation. This technique is also used in other endovascular procedures to deploy large intravascular devices, such as percutaneous aortic valves, angioplasty balloons, stents, and IVC filters. While others have described successful placement of the Avalon dual-lumen bicaval cannula using only echocardiographic guidance, this report illustrates the importance of continuous visualization of the entire guidewire during dilation and Avalon cannula placement.5,8
Knowledge regarding optimal and safe endovascular approaches to Avalon bicaval dual-lumen single cannula placement is necessary for practitioners in ECMO institutions. When conditions are prohibitive for the placement of an Avalon bicaval dual-lumen cannula at the initial ECMO cannulation, it is possible to transition to Avalon bicaval single cannula ECMO support when clinical status improves to promote early mobility and reconditioning.
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