Yezan Abderrahman, MD
Pediatric Critical Care Fellow
University of Iowa Hospital and Clinics
Iowa City, IA, United States
Disclosure information not submitted.
Ramya Deepthi Billa, MBBS
University of Iowa Stead Family Children's Hospital
Iowa City, IA
Disclosure information not submitted.
Aditya Badheka, MD, MS
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospital and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Cody Tigges, DO
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Bassel Mohammad Nijres, MD
Clinical Assistant Professor, Pediatric Cardiology
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Title: Adjusting Avalon Venovenous ECMO Cannula Migration Into Hepatic Veins With Sheath and Wire Approach
Introduction: Double lumen bicaval cannula is commonly used for extracorporeal membrane oxygenation (ECMO) support in acute hypoxemic respiratory failure. Optimal positioning of the cannula is essential to facilitate adequate oxygenation, prevent recirculation and avoid complications.
Description: A 2-year-old male presented with acute hypoxemic respiratory failure secondary to severe ARDS and was placed on venovenous ECMO for hypoxemia refractory to invasive conventional ventilation, utilizing a 20 Fr Avalon cannula. During his ECMO run he developed positional hypoxemia and transthoracic echocardiography (TTE) showed ECMO cannula migration from the IVC to the middle hepatic vein. Liver doppler studies revealed normal triphasic flow through the hepatic veins. No elevation in liver enzymes was observed. Due to his inability to tolerate cessation of ECMO flow we attempted to reposition the cannula using the classic manual approach but without a wire, but these attempts failed. Subsequently we attempted a different approach where a 5Fr sheath was placed at the proximal portion of the inflow tube close to its connection with the cannula. A 0.035" J-tip wire was advanced through the sheath. However, a small amount of air was introduced into the circuit presumably through the valve of the sheath in the setting of having negative pressure in the inflow tube. The Problem was solved with brief periods of ECMO pauses by pushing the zero flow button, meanwhile manipulating a combination of 4 Fr Angle Glide (AG) catheter and a J tip wire. The inferior vena cava (IVC) was accessed, and the cannula was slid over the combination of AG catheter and J tip wire into the hepatic IVC. Wire and catheter were removed. The tube just proximal and distal to the sheath was clamped, then was cut at the insertion site and both ends were reconnected using a sterile ¼" to ¼" connector. TTE and fluoroscopy were utilized to guide cannula repositioning successfully.
Discussion: Cannula migration is a major problem of the Avalon dual lumen cannula. Optimal cannula positioning is crucial during ECMO to avoid oxygen desaturation and hepatic complications. When classic manual repositioning fails, our described technique can be effective while minimizing cessation of ECMO flow.