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Venoarterial Extracorporeal Membrane Oxygenation: Simplified Tunneled Technique Using Arterial Grafting and Saphenofemoral Cannulation
Keith B. Allen, A. Michael Borkon, Sanjeev Aggarwal, Michelle Haines, J Russell Davis, Troy Sydzyik, Alex Pak, Jim Stewart, R. Scott Stuart.
St. Luke's Hospital, Mid America Heart and Vascular Institute, Kansas City, MO, USA.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation(VA-ECMO) has experienced a resurgence, however, cannulation site morbidity including bleeding, infection, and limb ischemia remain problematic. We describe a novel approach using a tunneled graft sewn to the common femoral artery (CFA) and venous cannulation through the saphenofemoral junction (SFJ) that offers decreased morbidity and simplifies decannulation.
METHODS: From June 2009 through Dec 2012, VA-ECMO was instituted in 26 patients using a Quadrox Oxygenator (Maquet) and a Revolution Pump (Sorin). Salvage patients were emergently cannulated percutaneously, however, in our most recent 9 non-salvage patients VA-ECMO was established with a femoral cut down with these modifications. Venous cannulation was achieved by isolating the SFJ and placing a 0.35 guide wire from the anterior thigh into the saphenous vein approximately 2cm distal to the SFJ. A 25F Bio-Medicus (Medtronic) cannula was then advanced into the right atrium with echo guidance. Arterial cannulation was achieved by sewing an 8mm Hemashield (Maquet) graft to the CFA which was then tunneled to the anterior thigh. A 22F Optisite Arterial Cannula (Edwards) was inserted into the graft with the tip of the cannula placed just outside the CFA to avoid distal limb ischemia.
Decannulation involved re-exposing the femoral vessels, ligating the SFJ and dividing the vascular graft with an endostapler (Ethicon) as the cannulas were removed.
RESULTS: There were no (0/9) cannulation-related complications with this technique including no bleeding, infection, or limb ischemia. Average time required to establish VA-ECMO was 32 minutes. Average time on VA-ECMO was10 days. Survival to discharge was 67% (6/9). Among survivors, decannulation was uneventfully completed at the bedside in three patients and in the operating room in three patients.
CONCLUSIONS: VA-ECMO can be safely established using a tunneled femoral approach with venous cannulation through the saphenofemoral junction and an arterial graft to the common femoral artery. This technique simplifies decannulation and may decrease common cannulation complications such as bleeding, infection, and limb ischemia.


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