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\begin{document}

\title{Alternative Position of Cannulae in Veno-venous Extracorporeal Membrane
Oxygenation}



\author[1]{Ui Won Go}%
\author[1]{Chang Hyu Choi}%
\author[1]{Chul Hyun Park}%
\author[1]{Seok In Lee}%
\affil[1]{Gachon University Gil Medical Center}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
Optimal positioning of drainage and return cannulae is critically
important for minimizing the recirculation in patients with respiratory
failure requiring veno-venous extracorporeal membrane oxygenation (VV
ECMO). If a drainage cannula is positioned at a low level of right
atrium through the femoral vein, flow disturbance due to drainage
chattering can occur when the intravascular volume is insufficient, or
intrathoracic or intraabdominal pressure is increased. We report a case
in which drainage chattering was eliminated and recirculation were
decreased by repositioning the drainage and return cannula in a patient
with VV ECMO flow disturbance when intrathoracic pressure was increased.%
\end{abstract}%



\sloppy


\textbf{Introduction}

When veno-venous extracorporeal membrane oxygenation (VV-ECMO) is
applied to a patient with severe respiratory failure, an optimal
cannulation technique is essential to minimize
recirculation.\textsuperscript{1} Recently, a dual lumen cannula for
VV-ECMO was reported that it was simple and useful for reducing
recirculation.\textsuperscript{2} The right internal jugular and right
common femoral veins are used in most common for the two vessel
cannulation technique. However, the femoral to internal jugular VV-ECMO
configuration with drainage and return ports in the inferior vena cava
(IVC) and superior vena cava (SVC), respectively, leads to recirculation
because the infusion jet is directed toward the drainage port. On the
other hand, if the drainage cannula is positioned at low level of right
atrium (RA) for decreasing recirculation, flow disturbance due to
drainage chattering from changing intrathoracic pressure can occur, can
be fatal when a patient is wholly dependent on VV-ECMO. We report a case
in which drainage chattering was eliminated and recirculation were
decreased by repositioning the drainage and return cannula in a patient
with VV ECMO flow disturbance when intrathoracic pressure was increased.

\textbf{Case report}

61-year old male (height; 167 cm, weight; 67 kg, body surface area; 1.76
m\textsuperscript{2}) with interstitial lung disease waiting for lung
transplantation was supported by VV-ECMO because his pulmonary function
was worsening. The cannulation was approached conventionally using
percutaneous procedure via the right internal jugular (return) and right
common femoral vein (drainage) using 15Fr and 23Fr HLS\selectlanguage{ngerman}© cannulae
(Maquet; Getinge Group, Rastatt, Germany), respectively (Figure 1A). A
terumo emergency bypass system (Terumo Corp., Tokyo, Japan) was used and
the ECMO was set 4.00 liters per minute, 2400 rotations per minute, an
inspired oxygen fraction of 1.0, and a sweep gas flow rate of 4.00
liters per minute. A 28\% recirculation rate was measured by the ELSA
monitor (Transonic Systems Inc., Ithaca, NY, USA, Figure
1B).\textsuperscript{3} Cardiac function and size, as measured by
transthoracic echocardiography, were normal without pulmonary
hypertension. We could maintain the protective ventilator setting, but
flow disturbance occurred due to chatter in the venous drainage circuit
when intrathoracic pressure was increased during suctioning in the
endotracheal tube. When the chattering occurred, unpredictable volume
was added to maintain VV-ECMO flow, and hypoxia was detected, therefore
ventilator had to change to the higher tidal volume and plateau airway
pressure than protective ventila, occasionally. Although the possibility
of recirculation could become higher, we repositioned the drainage
cannula at a higher level until SVC and then determined the position of
the return cannula by measuring a recirculation rate by the ELSA
monitor. Before positioning the return cannula, the recirculation rate
was 26\%. The first step of the repositioning procedure involved
advancing the return cannula 2 cm, which reduced the recirculation rate
to 30\%. Then we advanced the return cannula by more 1cm and decreased
ECMO flow slightly. At this stage, a recirculation rate was 24\% and the
VV-ECMO flow was remained stable. The protective ventilator setting was
also maintained. The next day, a recirculation rate was 14\% after
VV-ECMO flow was decreased from 4.4 to 4.0 LPM (Figure 2 and 3). After
12 hospital days on VV-ECMO support, lung transplantation was performed
successfully and the patient recovered well.

\textbf{Discussion}

VV-ECMO can be applied to patients that are severely hypoxemic and/or
hypercapnic despite optimal medical management, including ventilator
support. An important consideration of VV-ECMO cannulation is the
minimization of recirculation. Dual-site VV-ECMO is usually used in many
centers. This involves insertion of a drainage cannula into the femoral
vein and advancing it to the junction between the IVC and RA, and then
inserting the return cannula into the internal jugular vein and
advancing it through the SVC into the RA.\textsuperscript{4,5}

Recirculation refers to the reintroduction of oxygenated blood to the
drainage cannula without passing through the systemic circulation, and
reduces the efficiency of oxygenation by VV-ECMO. Various factors
influence recirculation, such as cannulation configuration, cannula
positioning, pump speed, extracorporeal blood flow, cannula size,
cardiac function, intrathoracic and intraabdominal pressures, and
direction of returned blood flow.\textsuperscript{2,6} In a previous
study, it was recommended that the use of a multistage cannula and
cannula position adjustment be used to minimize
recirculation.\textsuperscript{7} The author demonstrated that the
location of the most proximal holes of a multistage cannula drain a
larger fraction deoxygenated blood from the upper body and less from the
RA junction. Fifteen centimeter between the two cannulae is recommended
to decrease recirculation,\textsuperscript{4} but if the drainage
cannula is positioned at a lower level of RA for maintaining this
distance, the ECMO flow disturbance could occur due to chattering.
Single-site VV ECMO using a bicaval dual lumen cannula has recently been
reported to reduce recirculation as compared with dual site
cannulation.\textsuperscript{8} However, due to the high cost,
single-site VV ECMO could not always be available.

The cannulae position used in the present study have the benefits that
deoxygenated blood from upper and lower body are effectively drained,
and that VV-ECMO flow disturbance due to chattering can be prevented.
Using the described technique, we were able to reduce recirculation by
adjusting the position of the return cannula by the ELSA monitor, which
measures the amount of recirculation using the ultrasound dilution
technique. The cannula repositioning procedure described has an effect
similar to a single dual-lumen bicaval cannula but does not impose a
cost burden, and complication related to the procedure, such as
hemopericardium.\textsuperscript{9}

A similar cannula position, called the X-configuration, was reported to
reduce the blood recirculation fraction, significantly. However, this
configuration has weaknesses that could be used after modifying return
cannula by self, and might result in tricuspid valve injury or tricuspid
regurgitation if the cannula were positioned through the tricuspid
valve.\textsuperscript{10}

\textbf{Conclusion}

This report highlight is the described cannula repositioning procedure
enabled VV-ECMO flow to be maintained at full support without
unnecessary volume addition in a patient even with a low intravascular
volume or high intrathoracic/intraabdominal pressure, and recirculation
rate could be reduced by ELSA monitor.

Figure 1. Chest AP (1A) and result of ELSA monitor (1B) after applying
VV ECMO. The cannula positioned at superior vena cana and junction of
right atrium and inferior vena cava. The recirculation, measured by ELSA
monitor, was 28\%. (Yellow arrow; return cannula, black dot arrow;
drainage cannula)

Figure 2. Alternative position of cannulae. A drainage cannula (black
dot arrow) was positioned at a higher level until SVC. Overlap distance
was 8.75cm between a return cannula (yellow arrow) and a drainage
cannula. (2A; chest anteroposterior view, 2B; chest left lateral view)

Figure 3. ELSA monitor during changing a position of cannulae.

3A) Before positioning the return cannula, a recirculation rate was
26\%.

3B) After advancing the return cannula 2 cm, a recirculation rate was
30\%.

3C) After advancing the return cannula by more 1cm, a recirculation rate
was 24\%.

3D) The next day, a recirculation rate was 14\% after VV-ECMO flow was
decreased.

\textbf{References}

1. Burrell AJC, Ihle JF, Pellegrino VA, Sheldrake J, Nixon PT.
Cannulation technique: femoro-femoral. J Thorac Dis. 2018;10:S616--S623.

2. Abrams D, Bacchetta M, Brodie D, Recirculation in venovenous
extracorporeal membrane oxygenation, ASAIO J. 2015 Mar-Apr;61:115-21.

3. Darling EM, Crowell T, Searles BE. Use of dilutional ultrasound
monitoring to detect changes in recirculation during venovenous
extracorporeal membrane oxygenation in swine. ASAIO J. 2006
Sep-Oct;52:522-4.

4. Banfi C, Pozzi M, Siegenthaler N, et al. Veno-venous extracorporeal
membrane oxygenation: cannulation techniques. J Thorac Dis.
2016;8:3762--3773.

5. Shaheen A, Tanaka D, Cavarocchi NC, Hirose H. Veno-Venous
Extracorporeal Membrane Oxygenation (V\selectlanguage{english} V ECMO): Indications,
Preprocedural Considerations, and Technique. J Card Surg. 2016
Apr;31:248-52.

6. Togo K, Takewa Y, Katagiri N, et al. Impact of bypass flow rate and
catheter position in veno-venous extracorporeal membrane oxygenation on
gas exchange in vivo. J Artif Organs. 2015;18:128-135.

7. Palmer O, Palmer K, Hultman J, Broman M. Cannula Design and
Recirculation During Venovenous Extracorporeal Membrane Oxygenation.
ASAIO J. 2016 Nov/Dec;62:737-742.

8. 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
Sep;90:991-5.

9. Rubino A, Vuylsteke A, Jenkins DP, Fowles JA, Hockings L, Valchanov
K. Direct complications of the Avalon bicaval dual-lumen cannula in
respiratory extracorporeal membrane oxygenation (ECMO): Single-center
experience. Int J Artif Organs. 2014;37:741--7.

10. Bonacchi M, Harmelin G, Peris A, Sani G. A novel strategy to improve
systemic oxygenation in venovenous extracorporeal membrane oxygenation:
the ''\selectlanguage{greek}χ-\selectlanguage{english}configuration''. J Thorac Cardiovasc Surg. 2011
Nov;142:1197-204.

\textbf{Acknowledgements;} None.\selectlanguage{english}
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