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Cannulation and decannulation techniques for neonatal ECMO

Published:November 17, 2022DOI:https://doi.org/10.1016/j.siny.2022.101404

      Highlights

      • ECMO continues to be an important method of cardiovascular support when conventional treatments are inadequate.
      • Both VA-ECMO and VV-ECMO are suitable options for ECLS, with modality dependent on indication.
      • For VA-ECMO cannulations, cannula location may be confirmed with echocardiography in cases of altered anatomy.
      • For VV-ECMO cannulation, placement should be guided by fluoroscopy or echocardiography and confirmed with echocardiography.
      • For VA-ECMO, some centers perform carotid ligation while some repair the vessels. Data suggest that there is minimal difference in neurological outcomes with either of these practice patterns.
      • All ECMO cannulae have risk of cardiac or vascular complications and need for repositioning. Continued product innovation will be crucial to decrease these inherent risks.
      • Further randomized controlled trials are needed to determine whether there truly is a difference between ligation and repair of the carotid artery with VA-ECMO
      • More prospective data are needed to quantify the potential advantages and expanding use of VV-ECMO in those patients who might otherwise be supported by VA-ECMO

      Abstract

      In neonates with cardiac and/or respiratory failure, extracorporeal membrane oxygenation (ECMO) continues to be an important method of respiratory and/or cardiovascular support where conventional treatments are failing. ECMO cannulation involves a complex decision-making process to choose the proper ECMO modality and cannulation strategy to match each patient's needs, unique anatomy, and potential complication profile. Initially, all ECMO support involved cannulating both the carotid artery and the internal jugular vein (IJV), known as veno-arterial (VA-ECMO) for cardiac and/or respiratory support. Rarely was cannulation through the chest used. The development of dual-lumen cannulae in the early to mid 1990s addressed the concerns about carotid artery ligation and its impact on neurological outcomes, and allowed single vascular access for veno-venous respiratory support (VV-ECMO). We present a review of cannulation and decannulation techniques for both VA and VV-ECMO in neonates.

      Keywords

      Abbreviations:

      ECMO (Extracorporeal Membrane Oxygenation), ECLS (Extracorporeal Life Support), VA (Venoarterial), VV (Venovenous), IJV (Internal Jugular Vein)
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      References

        • Bartlett R.H.
        • Isherwood J.
        • Moss R.A.
        • Olszewski W.L.
        • Polet H.
        • Drinker P.A.
        A toroidal flow membrane oxygenator: four day partial bypass in dogs.
        Surg Forum. 1969; 20: 152-153
        • Hanson E.L.
        • Bartlett R.H.
        • Burns N.E.
        • et al.
        Prolonged use of a membrane oxygenator in air-breathing and hypoxic lambs. I. Venovenous bypass.
        Surgery. 1973; 73: 284-298
        • Fong S.W.
        • Burns N.E.
        • Williams G.
        • Woldanski C.
        • Gazzaniga A.B.
        • Bartlett R.H.
        Changes in coagulation and platelet function during prolonged extracorporeal circulation (ECC) in sheep and man.
        Trans Am Soc Artif Intern Organs. 1974; 20A: 239-247
        • Kolobow T.
        • Zapol W.
        • Pierce J.E.
        • Keeley A.F.
        • Replogle R.L.
        • Haller A.
        Partial extracorporeal gas exchange in alert newborn lambs with a membrane artificial lung perfused via an A-V shunt for periods up to 96 hours.
        Trans Am Soc Artif Intern Organs. 1968; 14: 328-334
        • Kolobow T.
        • Zapol W.M.
        • Sigman R.L.
        • Pierce J.
        Partial cardiopulmonary bypass lasting up to seven days in alert lambs with membrane lung blood oxygenation.
        J Thorac Cardiovasc Surg. 1970; 60: 781-788
        • Zwischenberger J.B.
        • Toomasian J.M.
        • Drake K.
        • Andrews A.F.
        • Kolobow T.
        • Bartlett R.H.
        Total respiratory support with single cannula venovenous ECMO: double lumen continuous flow vs. single lumen tidal flow.
        Trans Am Soc Artif Intern Organs. 1985; 31: 610-615
        • Klein M.D.
        • Andrews A.F.
        • Wesley J.R.
        • et al.
        Venovenous perfusion in ECMO for newborn respiratory insufficiency. A clinical comparison with venoarterial perfusion.
        Ann Surg. 1985; 201: 520-526
        • Stroud C.C.
        • Meyer S.L.
        • Bawkon M.C.
        • Smith H.G.
        • Klein M.D.
        Vascular access for extracorporeal circulation. Resistance in double lumen cannulas.
        ASAIO (Am Soc Artif Intern Organs) Trans. 1991; 37: M418-M419
        • Andrews A.F.
        • Klein M.D.
        • Toomasian J.M.
        • Roloff D.W.
        • Bartlett R.H.
        Venovenous extracorporeal membrane oxygenation in neonates with respiratory failure.
        J Pediatr Surg. 1983; 18: 339-346
        • Javidfar J.
        • Brodie D.
        • Wang D.
        • et al.
        Use of bicaval dual-lumen catheter for adult venovenous extracorporeal membrane oxygenation.
        Ann Thorac Surg. 2011; 91 (; discussion 1769): 1763-1768
        • Bazan V.M.
        • Taylor E.M.
        • Gunn T.M.
        • Zwischenberger J.B.
        Overview of the bicaval dual lumen cannula.
        Indian J Thorac Cardiovasc Surg. 2021; 37: 232-240
        • Ramaraj A.
        • Jensen G.
        • Rice-Townsend S.
        • DiGeronimo R.
        • Yalon L.
        • Stark R.
        Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population.
        Perfusion. 2021; 2676591211030767
        • Lazar D.A.
        • Cass D.L.
        • Olutoye O.O.
        • et al.
        Venovenous cannulation for extracorporeal membrane oxygenation using a bicaval dual-lumen catheter in neonates.
        J Pediatr Surg. 2012; 47: 430-434
        • Charlesworth M.
        • Ashworth A.D.
        Reducing the risk of cardiac perforation during placement of bicaval veno-venous extracorporeal membrane oxygenation cannulae.
        J Cardiothorac Vasc Anesth. 2018; 32: e19-e20
        • Jarboe M.D.
        • Gadepalli S.K.
        • Church J.T.
        • Arnold M.A.
        • Hirschl R.B.
        • Mychaliska G.B.
        Avalon catheters in pediatric patients requiring ECMO: placement and migration problems.
        J Pediatr Surg. 2018; 53: 159-162
        • Teman N.R.
        • Haft J.W.
        • Napolitano L.M.
        Optimal endovascular methods for placement of bicaval dual-lumen cannulae for venovenous extracorporeal membrane oxygenation.
        Am Soc Artif Intern Organs J. 2013; 59: 442-447
        • Czerwonko M.E.
        • Fraga M.V.
        • Goldberg D.J.
        • Hedrick H.L.
        • Laje P.
        Cardiovascular perforation during placement of an Avalon Elite(R) Bicaval dual lumen ECMO cannula in a newborn.
        J Card Surg. 2015; 30: 370-372
        • Berdajs D.
        Bicaval dual-lumen cannula for venovenous extracorporeal membrane oxygenation: Avalon(c) cannula in childhood disease.
        Perfusion. 2015; 30: 182-186
        • Tipograf Y.
        • Gannon W.D.
        • Foley N.M.
        • et al.
        A dual-lumen bicaval cannula for venovenous extracorporeal membrane oxygenation.
        Ann Thorac Surg. 2020; 109: 1047-1053
        • Salazar P.A.
        • Blitzer D.
        • Dolejs S.C.
        • Parent J.J.
        • Gray B.W.
        Echocardiographic guidance during neonatal and pediatric jugular cannulation for ECMO.
        J Surg Res. 2018; 232: 517-523
        • Kurkluoglu M.
        • Badia S.
        • Peer S.M.
        • Jonas R.
        • Shankar V.
        • Sinha P.
        Patency of common carotid artery and internal jugular vein after a simple vessel sparing cannulation for extracorporeal membrane oxygenation support.
        J Pediatr Surg. 2017; 52: 1806-1809
        • Cianchi G.
        • Lazzeri C.
        • Bonizzoli M.
        • Batacchi S.
        • Peris A.
        Echo-guided insertion of a dual-lumen cannula for venovenous extracorporeal membrane oxygenation.
        Am Soc Artif Intern Organs J. 2019; 65: 414-416
        • Javidfar J.
        • Wang D.
        • Zwischenberger J.B.
        • et al.
        Insertion of bicaval dual lumen extracorporeal membrane oxygenation catheter with image guidance.
        Am Soc Artif Intern Organs J. 2011; 57: 203-205
        • Lillie J.
        • Pienaar A.
        • Budd J.
        • et al.
        Multisite veno-venous cannulation for neonates and nonambulatory children.
        Pediatr Crit Care Med. 2021; 22: 692-700
        • Rose A.T.
        • Davis J.
        • Williams H.O.
        • Clifton M.
        • Paden M.
        • Keene S.D.
        Utility of cephalic drains in infants receiving extracorporeal membrane oxygenation.
        Perfusion. 2022; 2676591221080506
        • Hafezi N.
        • Naeem B.
        • Colgate C.
        • et al.
        Cephalic drain use in neonatal respiratory VA ECMO: an ELSO database study 32nd annual ELSO meeting.
        Indiana University School of Medicine, 2021
        • Campbell L.R.
        • Bunyapen C.
        • Holmes G.L.
        • Howell Jr., C.G.
        • Kanto Jr., W.P.
        Right common carotid artery ligation in extracorporeal membrane oxygenation.
        J Pediatr. 1988; 113: 110-113
        • Duggan E.M.
        • Maitre N.
        • Zhai A.
        • et al.
        Neonatal carotid repair at ECMO decannulation: patency rates and early neurologic outcomes.
        J Pediatr Surg. 2015; 50: 64-68
        • Carpenter J.L.
        • Baker M.
        • Sperberg K.
        • Berger J.T.
        • Vezina G.
        • Sinha P.
        Common carotid artery imaging after vessel sparing decannulation from Extracorporeal Membrane Oxygenation (ECMO) support.
        J Pediatr Surg. 2021; 56: 2305-2310
        • Pearce F.B.
        • Kirklin J.K.
        • Knott-Craig C.J.
        • et al.
        Patency of internal jugular vein following repair after ECMO stabilization prior to Berlin Heart implantation: utility of repaired vein for subsequent cardiac catheterization and biopsy.
        Congenit Heart Dis. 2008; 3: 411-414
        • Rauth T.P.
        • Scott B.P.
        • Thomason C.K.
        • Bartilson R.E.
        • Hann T.M.
        • Pietsch J.B.
        Central venous catheter placement at the time of extracorporeal membrane oxygenation decannulation: is it safe?.
        J Pediatr Surg. 2008; 43 (; discussion 58): 53-57
        • Antithrombotic Trialists C.
        Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.
        BMJ. 2002; 324: 71-86
        • Jacobs J.P.
        • Goldman A.P.
        • Cullen S.
        • et al.
        Carotid artery pseudoaneurysm as a complication of ECMO.
        Ann Vasc Surg. 1997; 11: 630-633
        • Duncan A.W.
        • Mawson J.B.
        • LeBlanc J.G.
        • Potts J.E.
        • Duncan W.J.
        Imaging of a carotid aneurysm in two patients following extracorporeal membrane oxygenation therapy.
        Pediatr Cardiol. 2009; 30: 1000-1002
        • Desai S.A.
        • Stanley C.
        • Gringlas M.
        • et al.
        Five-year follow-up of neonates with reconstructed right common carotid arteries after extracorporeal membrane oxygenation.
        J Pediatr. 1999; 134: 428-433
        • Adolph V.
        • Bonis S.
        • Falterman K.
        • Arensman R.
        Carotid artery repair after pediatric extracorporeal membrane oxygenation.
        J Pediatr Surg. 1990; 25 (; discussion 869-870): 867-869
        • Hendrikse J.
        • de Vries L.S.
        • Groenendaal F.
        Magnetic resonance angiography of cerebral arteries after neonatal venoarterial and venovenous extracorporeal membrane oxygenation.
        Stroke. 2006; 37: e15-e17
        • Sarioglu A.
        • McGahren E.D.
        • Rodgers B.M.
        Effects of carotid artery repair following neonatal extracorporeal membrane oxygenation.
        Pediatr Surg Int. 2000; 16: 15-18
        • Mitchell D.G.
        • Merton D.A.
        • Graziani L.J.
        • et al.
        Right carotid artery ligation in neonates: classification of collateral flow with color Doppler imaging.
        Radiology. 1990; 175: 117-123
        • Lohrer R.M.
        • Bejar R.F.
        • Simko A.J.
        • Moulton S.L.
        • Cornish J.D.
        Internal carotid artery blood flow velocities before, during, and after extracorporeal membrane oxygenation.
        Am J Dis Child. 1992; 146: 201-207