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

Abstract

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.

Echocardiography for extracorporeal membrane oxygenation

“…9 Presence of pre-existing pacemaker wires, central venous lines, peripherally inserted central catheters, and PA catheters can also hinder with both the identification of guidewires and the insertion and positioning of venous cannulas. 13…”

“…18 TEE provides an ideal imaging modality to guide placement of these single insertion site, dual lumen cannulas. 13 A summary of dual lumen cannulas and echocardiographic assessment can be found in Table 2 and Figure 2 provides images of the Avalon Elite (Figure 2A), Crescent (Figure 2B), and Protek Duo RD (Figure 2C) with detailed insets depicting the inflow and outflow ports.…”

“…In one small study, TEE was found to be superior to fluoroscopy in positioning the Avalon Elite cannula. 13 Care must be taken to…”

Monitoring during extracorporeal membrane oxygenation

“…Final assessment of cannula position should be made with the patient in a semi-recumbent position, and at mechanical ventilation parameters to be used during VV ECMO support (e.g., lung rest settings) [1, 8,15]. TEE guidance can also be employed for bedside bicaval dual-lumen cannulation [30,32]. If TEE is contraindicated, a combination of TTE with fluoroscopy can be used [32].…”

A Dual-Lumen Extracorporeal Membrane Oxygenation Cannulation Technique Using a Mobile X-Ray Device

“…Both techniques with their inherent advantages and disadvantages appear to be feasible and safe in experienced hands (Table 1). 7,8 However, the ubiquitous availability of digital bedside x-ray devices at our institution fostered the development of a novel bedside cannulation technique that overcomes most disadvantages of the originally described techniques.…”