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Minimally Invasive Central Cannulation For Extracorporeal Life Support: The "Uniportal" And "Subxiphoid" Approach
Dana Rizk1, Koray Durak1, Janina Emunds1, Felix Vorwold1, Sebastian Kalverkamp1, Flutura Hima1, Ulrich Steinseifer2, Lasse Strudthoff2, Jan Spillner1.
1RWTH Uniklinik Aachen, Aachen, Germany, 2Helmholtz-Institute for Biomedical Engineering, Aachen, Germany.
BACKGROUND: Extracorporeal life support (ECLS) is an established therapy in patients with cardiac and/or respiratory failure. Peripheral cannulation is less invasive but has inherent disadvantages. Hence, our objective was to develop a minimally invasive approach for central ECLS cannulation.
METHODS: Simulative experimental surgical evaluations were performed on piglet hearts which were positioned in a plastic thoracic model. An endoscopic camera and multiple endoscopic instruments were used. Two different minimally invasive cannulation approaches were evaluated. The first approach was subxiphoid cannulation via a five-centimeter vertical incision in the epigastrium. The second approach was "uniportal" and was carried out via a simulated 4th intercostal (non-ribspreading) access on the right side. All simulations were recorded and evaluated. Commercially available ECLS cannulas were used. Leakage tests were performed after surgical simulation.
RESULTS: From both access sites, it was possible to separate the pericardial sac from the anterior thoracic wall and a pericardial central bottom-up incision could be performed. Accessibility of potential cardiac structures and great vessels was evaluated for cannulation. Two purse-string sutures were placed on the selected locations. We attached graspable curved needles to flexible tubes to perform punctures. This enabled us to perform the Seldinger-technique on distances between 10-30 centimeters. Guidewires were pushed at least five centimeters into the ‘’drainage area’’; cannulas were equipped with graspable brackets to facilitate its advancement with endoscopic instruments. From the subxiphoid approach a cannulation of the aorta, main pulmonary artery, and atria was possible. The uniportal approach allowed a cannulation of the aorta, caval veins, atria, the main pulmonary artery and, in addition, its (extrapericardial) right branch. Evaluation of the specimens after surgical simulation revealed no damage to surrounding structures; leakage tests could demonstrate a tight sealing of the cannulation sites.
CONCLUSIONS: Both "uniportal" and "subxiphoid " central cannulation of all ECLS relevant sites were feasible in this surgical simulative study. These approaches seem to be of special interest for future thoracic assist surgery. Further investigations and animal testing are necessary before clinical application. Funded by the German Research Foundation (DFG): Project-Nr.347325614. 
LEGEND: The figure shows the construction and two different endoscopic images during aortic cannulation.
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