\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Bedside veno-venous ECMO cannulation}



\author[1]{Domenico Calcaterra}%
\author[2]{Beth Heather}%
\author[2]{Louis Kohl}%
\author[2]{Heidi Erickson}%
\author[2]{Mathhew Prekker}%
\affil[1]{Bethesda Heart Hospital Baptist South Florida}%
\affil[2]{Hennepin County Medical Center}%


\vspace{-1em}



  
  \date{March 14, 2025}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Patient selection and cannulation arguably represent the key steps for
the successful implementation of Extracorporeal Membrane Oxygenation
(ECMO) support. Cannulation is traditionally performed in the operating
room or the catheterization laboratory for a number of reasons,
including physician preference and access to real-time imaging, with the
goal of minimizing complications and ensuring appropriate cannula
positioning. Nonetheless, the patients' critical and unstable conditions
often require emergent initiation of ECMO and preclude the safe
transport of the patient to a procedural suite. Therefore, with the
objective of avoiding delay with initiation of therapy and reducing the
hazard of transport, we implemented a protocol for bedside ECMO
cannulation. In the current pandemic, this strategy may have additional
benefits for the care of patients with refractory acute respiratory
distress syndrome (ARDS) due to COVID-19 decreasing risk of healthcare
worker or other patients exposure to the novel SARS-CoV-2 virus
occurring during patient transport, preparation, or during disinfection
of the procedural suite and the transportation pathway after ECMO
cannulation.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Veno-venous (VV) ECMO has been recognized as a potentially life-saving
therapy for patients with refractory ARDS secondary to pneumonia and its
use in adults has increased exponentially following the influenza A
(H1N1) pandemic in 2009 (1-5). The Extracorporeal Life Support
Organization (ELSO) has published comprehensive guidelines defining the
appropriate clinical indications for VV-ECMO use and has established
detailed protocols and quality measures for to ensure appropriate
implementation of therapy (6,7).

Extracorporeal circulation in VV-ECMO is traditionally obtained with the
insertion of two venous cannulas either with the internal
jugular-femoral or the femoro-femoral configuration (5,8,9). In recent
years, a technique using a single bicaval dual-lumen catheter (Avalon
Elite\selectlanguage{ngerman}®, Maquet Inc., Rastatt, Germany) with access through the right
internal jugular vein (IJV) has become available as an alternative
method to the traditional double venous cannulation strategy (5,10,11).
The single insertion site, which may reduce the risk of bleeding and
infection, the location of the insertion site in the neck, which may
facilitate patients' prone positioning as needed, and possibly the more
efficient oxygenation, most likely related to lesser incidence of the
phenomenon of ``recirculation'', account for the advantages of using a
single dual-lumen cannula versus a double cannulation strategy
(8,9,12-14). On the other hand, the perceived technical difficulty of
the internal jugular venous cannulation using a large bore cannula (27
Fr or 31 Fr, both with an insertable length of 31 cm) is seen as a
potential disadvantage. For this reason, the dual lumen catheter IJV
placement is traditionally performed in the operating room or the
catheterization laboratory with assistance of fluoroscopy and
transesophageal echocardiography (11,15,16).

In 2015, we implemented a strategy of routine bedside cannulation at
Hennepin County Medical Center. An internal committee was created with
the objective of designing protocols and determining the logistics of
the cannulation procedure. Dry runs were simulated in the Surgical
Intensive Care Unit (SICU) until the optimal cannulation protocol was
defined. A total of 89 patients required ECMO support at Hennepin County
Medical Center between March 2015 and December 2019.~ Of these, 28
(31\%) patients were cannulated for veno-venous support, all at
bedside.~ A dual-lumen, bicaval cannula (Avalon Elite®, Maquet Inc.) was
used in 23 cases; a two cannula approach using the right internal
jugular vein and femoral vein was selected in 5 cases due to
patient-specific factors, such as a high native cardiac output.~ Of the
28 VV-ECMO cases, the average age was 40 years (range 12-66), 12 (43\%)
were women, and the average body surface area (BSA) was 2.04
m\textsuperscript{2} (range 1.53-2.71 ).~ Cannula size selection was
based on the patient's BSA.~ The indication for VV-ECMO was ARDS in all
cases; the etiology of ARDS was pneumonia (N=10, 36\%), massive
aspiration (N=7, 25\%), blunt trauma (N=8, 29\%), and drowning (N=3,
10\%).~Bedside cannulation was successful in 27 of 28 cases (97\%), and
there was no mortality or morbidity associated with the procedure.~ The
failed cannulation was in the case of a young woman who hanged herself.
Percutaneous access to the right IJV failed due to massive subcutaneous
emphysema; she was cannulated using a peripheral veno-arterial
configuration via the femoral vessels.~ ECMO blood flow achieved was
\textgreater{} 60\% of native cardiac output in all cases.~ The median
days of VV-ECMO support was 8 (range 1-37).~ Twenty of 28 patients
(71\%) undergoing VV-ECMO support survived to hospital discharge.

\textbf{Strategy and tips for cannulation:}

We designed a process of in-situ VV-ECMO cannulation based on the layout
of our intensive care unit (ICU) where patients with refractory
respiratory failure are routinely hospitalized (fig. 1). We utilize a
portable fluoroscopy bed which is placed to the side of the ICU bed
(fig. 2). After moving the patient from the ICU to the fluoroscopy bed,
the medical equipment is positioned around the patient to allow
convenient access to the right side of the neck as the cannula insertion
site (fig. 3). The procedure is completed under sterile conditions with
fluoroscopic guidance. Fluoroscopic guidance represent our preferred
imaging method since it may offer the highest level of safety (9,11).
However, in the absence of conditions allowing routine use of
fluoroscopy at the bedside, the procedure can also be safely performed
with transthoracic echocardiogram (TTE) to confirm guidewire and cannula
positioning (9, 17-19). Appropriate positioning of the wire can be
confirmed with subcostal views, making sure that the guidewire is
advanced into the retro-hepatic inferior vena cava (IVC) (9, 18-23).
Alternatively, imaging by portable chest X-ray can also be used to spot
check guidewire and cannula position (16).

Cannulation best practices using our approach are listed in table 1. We
always use real-time ultrasound visualization for the puncture of the
IJV. The patient is maintained in slight Trendelenburg position for the
entire duration of the procedure to reduce the risk of venous
air-embolism. The guidewire is advanced deep into the retrohepatic IVC
and its position is confirmed by imaging. We used the standard packaging
of the Avalon Elite® venous cannula kit (0.038'' x 210 cm change
guidewire) in all cases (table 2). After serial dilation of the skin and
soft tissue at the cannula insertion site, the IJV is cannulated with 10
Fr through 30 Fr dilators. The cannula is inserted under imaging
guidance ensuring no resistance is encountered while the catheter is
advanced through the right atrium into the IVC. The cannula is connected
to the ECMO circuit with meticulous de-airing and is secured to the skin
once final manual manipulation is made to ensure adequate extracorporeal
blood flow and desired arterial oxygenation (table 1).

\textbf{Discussion}

In our experience, the procedure of bedside VV-ECMO cannulation was safe
and effective. We had only one case of failed IJV single-cannula
insertion which required veno-arterial cannulation using the common
femoral artery and vein due to anatomic constraints. All procedures were
performed in the ICU under fluoroscopic and echocardiographic guidance.
Our set-up allowed the efficient utilization of fluoroscopy by using a
mobile, x-ray compatible bed (figures 1,2)). We selected the use of a
bicaval dual-lumen cannula whenever indicated to facilitate adequate
ECMO flow and optimize blood oxygenation by reducing ``recirculation''
(5,12,24). Although there is a lack of randomized trials comparing the
effectiveness of the single dual-lumen versus a double venous
cannulation strategy, clinical data and experimental studies show at
least comparable flow-parameters and clinical results (24, 25).
Nonetheless, the location of the cannula on the side of the neck, as
compared to the groin, provides more opportunity for patient
mobilization and may offer significant advantages in light of the fact
that VV-ECMO support is often required for a considerable length of
time.

The benefits of in-situ ECMO cannulation, not only in terms of
potentially expediting the timing of initiation of therapy and
decreasing the hazard of transporting the patient to the procedural
location, appears of crucial importance during the COVID-19 pandemic in
the extreme cases of respiratory decompensation and refractory hypoxemia
which may benefit from VV-ECMO support. Avoidance of transporting the
patient out of the ICU to reach the designated cannulation location
reduces the risk of SARS-CoV-2 virus transmission to other patients and
healthcare providers while also decreasing the risk of environmental
contamination inevitably associated with the transportation process, and
possibly decreasing unnecessary personal-protective-equipment (PPE)
usage outside of the ICU. The use of fluoroscopic guidance has
represented the standard for our protocol, however cannulation can also
be safely completed using echocardiographic imaging with TTE or even
using portable chest x-ray, which can be both routinely arranged at any
healthcare facility. No matter of the imaging technique used, single
venous cannulation with bicaval dual-lumen catheter remains a highly
demanding procedure with risk of life-threatening complications, so that
it should be performed by experienced operators in highly specialized
centers (21,23,26).

\textbf{Conclusions}

Our experience shows that adequate planning of veno-venous ECMO
cannulation allows safe completion of the procedure at bedside. This
strategy can be particularly useful in patients with refractory
hypoxemia due to COVID-19 associated severe ARDS as bedside cannulation
can minimize the inadvertent nosocomial transmission of this highly
contagious disease. Veno-venous ECMO management is resource-intensive
and limited to specialized referral centers but can be used as salvage
therapy in patients with refractory respiratory failure who have
preserved life-expectancy and few associated end-organ failures.
Certainly, we acknowledge the ethical dilemma of patient selection for
access to life-sustaining extracorporeal support during this pandemic.
Nonetheless, the opportunity of saving even a relatively small number of
patients in comparison to the large loss of lives produced by this
highly lethal disease cannot be ignored.

\emph{Reference}

\begin{enumerate}
\tightlist
\item
  Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest
  P, Gattas D, Granger E, Herkes R: Extracorporeal membrane oxygenation
  for 2009 influenza A (H1N1) acute respiratory distress syndrome. JAMA.
  2009, 302 (17): 1888-1895.
\item
  Holzgraefe B, Broom M, Kalzen H, Konrad D, Palmer K, Frenckner B:
  Extracorporeal membrane oxygenation for pandemic H1N1 2009 respiratory
  failure. Minerva Anestesiol. 2010, 76 (12): 1043-1051.
\item
  Grasselli G, Bombino M, Patroniti N, Foti G, Benini A, Abbruzzese C,
  Fumagalli R, Pesenti A: Management of acute respiratory complications
  from influenza A (H1N1) infection: experience of a tertiary-level
  Intensive Care Unit. Minerva Anestesiol. 2011, 77 (9): 884-891.
\item
  Noah MA, Peek GJ, Finney SJ, Griffiths MJ, Harrison DA, Grieve R,
  Sadique MZ, Sekhon JS, McAuley DF, Firmin RK: Referral to an
  extracorporeal membrane oxygenation center and mortality among
  patients with severe 2009 influenza A (H1N1). JAMA. 2011, 306 (15):
  1659-1668
\item
  Tulman DB, Stawicki SP, Whitson BA, Gupta SC, Tripathi RS, Firstenberg
  MS, Hayes D Jr, Xu X, Papadimos TJ\emph{.} Veno-venous ECMO: a
  synopsis of nine key potential challenges, considerations, and
  controversies. BMC Anesthesiol. 2014 Aug 6;14:65
\item
  Extracorporeal Life Support Organization Guidelines.
  http://www.elsonet.org/index.
\item
  The Extracorporeal Life Support Organization (ELSO). ELSO
  Anticoagulation Guideline. 2014. Available online:
  https://www.elso.org/portals/0/files/elsoanticoagulationguideline8-2014-table-contents.pdf
\item
  Jayaraman AL, Cormican D, Shah P, Ramakrishna H. Cannulation
  strategies in adult veno-arterial and veno-venous extracorporeal
  membrane oxygenation: Techniques, limitations, and special
  considerations. Ann Card Anaesth. 2017 Jan;20(Supplement):S11-S18
\item
  Ngai CW, Ng PY, Sin WC. Bicaval dual lumen cannula in adult
  veno-venous extracorporeal membrane oxygenation-clinical pearls for
  safe cannulation\emph{.} J Thorac Dis. 2018 Mar;10(Suppl 5):S624-S628
\item
  Bermudez CA, Rocha RV, Sappington PL, Toyoda Y, Murray HN, Boujoukos
  AJ: Initial experience with single cannulation for venovenous
  extracorporeal oxygenation in adults. Ann Thorac Surg. 2010, 90 (3):
  991-995.
\item
  Teman NR, Haft JW, Napolitano LM. Optimal endovascular methods for
  placement of bicaval dual-lumen cannulae for venovenous extracorporeal
  membrane oxygenation. ASAIO J. 2013 Jul-Aug;59(4):442-7
\item
  Lindholm JA. Cannulation for veno-venous extracorporeal membrane
  oxygenation. J Thorac Dis. 2018 Mar;10(Suppl 5):S606-S612
\item
  Banfi C, Pozzi M, Siegenthaler N, Brunner ME, Tassaux D, Obadia JF,
  Bendjelid K, Giraud R. Veno-venous extracorporeal membrane
  oxygenation: cannulation techniques. J Thorac Dis. 2016
  Dec;8(12):3762-3773
\item
  Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in
  adults. N Engl J Med 2011;365:1905-14.
\item
  Griffee MJ, Tonna JE, McKellar SH, Zimmerman JM. Echocardiographic
  Guidance and Troubleshooting for Venovenous Extracorporeal Membrane
  Oxygenation Using the Dual-Lumen Bicaval Cannula. J Cardiothorac Vasc
  Anesth. 2018 Feb;32(1):370-378
\item
  Griffee MJ, Zimmerman JM, McKellar SH, Tonna JE.
  Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane
  Oxygenation Cannula Placement in the ICU-A Retrospective Review. J
  Cardiothorac Vasc Anesth. 2020 Mar;34(3):698-705
\item
  Trimlett R.H., Cordingley J.J., Griffiths M.J., et al: A modified
  technique for insertion of dual lumen bicaval cannulae for venovenous
  extracorporeal membrane oxygenation. Intensive Care Med 2011; 37: pp.
  1036-1037
\item
  Dolch M.E., Frey L., Buerkle M.A., et al: Transesophageal
  echocardiography-guided technique for extracorporeal membrane
  oxygenation dual-lumen catheter placement. ASAIO J 2011; 57: pp.
  341-343
\item
  Chimot L., Marque S., Gros A., et al: Avalon bicaval dual-lumen
  cannula for venovenous extracorporeal membrane oxygenation: Survey of
  cannula use in France. ASAIO J 2013; 59: pp. 157-161
\item
  Tabak B, Elliott CL, Mahnke CB, et al. Transthoracic echocardiography
  visualization of bicaval dual lumen catheters for veno-venous
  extracorporeal membrane oxygenation. J Clin Ultrasound 2012;40:183-6
\item
  Yastrebov K, Manganas C, Kapalli T, et al. Right ventricular loop
  indicating malposition of J-wire introducer for double lumen bicaval
  venovenous extracorporeal membrane oxygenation (VV ECMO) cannula.
  Heart Lung Circ 2014;23:e4-7
\item
  Shaheen A, Tanaka D, Cavarocchi NC, et al. Veno-Venous Extracorporeal
  Membrane Oxygenation (V V ECMO): Indications, Preprocedural
  Considerations, and Technique. J Card Surg 2016;31:248-52
\item
  Camboni D, Philipp A, Lubnow M, et al. Extracorporeal membrane
  oxygenation by single-vessel access in adults: advantages and
  limitations. ASAIO J 2012;58:616-21
\item
  L. Christian Napp, Christian Kühn, Marius M. Hoeper, Jens
  Vogel-Claussen, Axel Haverich, Andreas Schäfer, Johann Bauersachs.
  Cannulation strategies for percutaneous extracorporeal membrane
  oxygenation in adults. Clin Res Cardiol. 2016; 105: 283--296
\item
  Kuhl T, Michels G, Pfister R, Wendt S, Langebartels G, Wahlers T.
  Comparison of the Avalon Dual-Lumen Cannula with Conventional
  Cannulation Technique for Venovenous Extracorporeal Membrane
  Oxygenation. Thorac Cardiovasc Surg 2015; 63(08): 653-662
\item
  Wang S, Force M, Kunselman AR, Palanzo D, Brehm C, Ündar A.
  Hemodynamic Evaluation of Avalon Elite Bi-Caval Dual Lumen Cannulas
  and Femoral Arterial Cannulas. Artif Organs. 2019 Jan;43(1):41-53
\item
  Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular
  rupture and tamponade caused by malposition of the Avalon cannula for
  venovenous extracorporeal membrane oxygenation. J Cardiothorac Surg.
  2012 Apr 20;7:36
\end{enumerate}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure1/Figure1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure2/Figure2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure3/Figure3}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`Avalon Cannula InsertionTable1last.docx`  available at \url{https://authorea.com/users/313652/articles/444136-bedside-veno-venous-ecmo-cannulation}

\textbf{Hosted file}

\verb`Table 2.docx`  available at \url{https://authorea.com/users/313652/articles/444136-bedside-veno-venous-ecmo-cannulation}

\selectlanguage{english}
\FloatBarrier
\end{document}

