Echocardiographic guidance for Avalon Elite dual-lumen catheter implantation

Dual lumen cannulation and mobilization of patients with venovenous extracorporeal membrane oxygenation

BACKGROUND

Mobilization is important in longer courses in intensive care unit (ICU), typical for patients requiring venovenous extracorporeal membrane oxygenation (V-V ECMO). For patients supported with ECMO, especially out-of-bed mobilizations improve outcome. We hypothesized that utilization of a dual lumen cannula (DLC) for V-V ECMO would facilitate out-of-bed mobilization compared to single lumen cannulas (SLC).

METHODS

Retrospective single center registry study including all V-V ECMO patients cannulated between 10/2010 and 05/2021 for respiratory failure.

RESULTS

The registry included 355 V-V ECMO patients (median age 55.6 years, 31.8% female, 27.3% with preexisting pulmonary disease), 289/355 (81.4%) primary cannulated with DLC, and 66/355 (18.6%) using SLC. Both groups had similar pre-ECMO characteristics. The runtime of the first ECMO cannula was significantly longer in DLC compared to SLC (169 vs. 115 h, p = 0.015). The frequency of prone positioning during V-V ECMO was similar in both groups (38.4 vs. 34.8%, p = 0.673). There was no difference in in-bed mobilization (41.2 vs. 36.4%, for DLC and SLC, respectively, p = 0.491). Patients with DLC were more often mobilized out-of-bed (25.6 vs. 12.1%, OR 2.495 [95% CI 1.150 to 5.268], for DLC and SLC, respectively, p = 0.023). Hospital survival was similar in both groups (46.4 vs. 39.4%, for DLC and SLC, respectively, p = 0.339).

CONCLUSION

Patients cannulated with a dual lumen cannula for V-V ECMO support were significantly more often mobilized out-of-bed. Since mobilization is important in prolonged ICU courses typical for ECMO patients, this might be an important benefit. Other benefits of DLC were the longer runtime of the initial cannula set and fewer suction events.

Bicaval dual lumen cannula placement using transthoracic echocardiography in COVID-19 scenario: pearls and pitfalls

A woman in her 50s who had been diagnosed with COVID-19 developed deep vein thrombosis in the left femoral vein extending into inferior vena cava (IVC). An IVC filter was placed to prevent fatal pulmonary embolism. Her respiratory failure subsequently deteriorated despite optimal mechanical ventilation and required venovenous extracorporeal membrane oxygenation (VV-ECMO) as a rescue therapy. Femoro-jugular VV-ECMO configuration was not suitable due to the IVC filter, hence a single-site venous cannulation using bicaval dual lumen (AvalonElite) cannula was selected. Placement of the Avalon cannula conventionally requires guidance by fluoroscopy or transoesophageal echocardiography, which were not feasible in COVID-19 patients. Hence, transthoracic echocardiography guidance was chosen. Guidewire looping into the right ventricle might lead to cannula malposition and imminent right ventricular rupture, but these could be detected by 'bending' sign. Transthoracic echocardiography could be a feasible guidance method for Avalon cannulation, nonetheless a thorough protocol should be followed to avoid cannula malposition during the procedure.

Transesophageal Echocardiography Compared to Fluoroscopy for Avalon Bicaval Dual-Lumen Cannula Positioning for Venovenous ECMO

The Avalon elite bicaval dual-lumen cannula for single site VenoVenous Extracorporeal Membrane Oxygenation (VV ECMO) offers several advantages. Correct placement of the Avalon cannula is safe using image guidance and needs either fluoroscopy or Transesophageal echocardiography (TEE). We assessed our institutional ECMO performance, cannulation related complications, instances of cannula malposition among patients cannulated using the two imaging modalities. We reviewed all patients who had Avalon cannula placement for VV ECMO at our institute. Ten patients were included in the study. Patients were cannulated using either fluoroscopy (Group A, n = 5) or TEE (Group B, n = 5). Data included patient demographics, diagnosis, evidence of cannula malposition, ECMO performance, cannulation related complications. The primary outcomes ease of cannulation; cannula malposition and the need for repositioning were compared between the two groups. Visualisation of guidewire, Avalon cannula and the average number of attempts to cannulate were similar (P > 0.05) between the two groups. Four patients cannulated using fluoroscopy had low flows whereas none of the patients cannulated using TEE had flow problems which was statistically significant (P = 0.024). Four cannulas (80%) placed under fluoroscopy required repositioning whereas one cannula (20%) placed under TEE needed repositioning. This difference was not statistically significant though (P = 0.099). TEE is the ideal imaging modality to guide Avalon elite cannula placement for VV ECMO.

Bedside repositioning of a dislocated Avalon-cannula in a running veno-venous ECMO

We report a repositioning maneuver of a dislocated Avalon Elite dual lumen catheter during ongoing veno-venous ECMO support. The inferior tip of the catheter dislocated into a liver vein, which was accompanied by a dramatic decrease in pump flow. After standard repositioning maneuvers under transthoracic echocardiographic guidance had failed, a special guiding sheath was inserted into the main lumen through a Y-connector with a valve. Over this valve, a stiff wire could be placed into the inferior vena cava to help guiding the catheter back into the correct position.