An emerging problem: Vascular access for ECMO

Transcription

1 An emerging problem: Vascular access for ECMO Dott.ssa Maria Grazia Calabrò U.O. Anestesia e Terapia Intensiva Cardio-Toraco-Vascolare Ospedale San Raffaele, Milano Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo.

2 VA ECMO Circuit Cannulae (outflow/inflow) ü Tubing Centrifugal pump ü Controller ü Blender ü Heat exchanger Membrane oxygenator Clin Chest Med 36 (2015)

3 Setting ü Operating Room à Postcardiotomy CGS ü Intensive Care Unit à Refractory CGS ü Cath Lab à Prophylactic/urgent circulatory support ü Emergency Room à ECPR for IHCA/OHCA without ROSC

4 VA ECMO configurations Central VA ECMO Peripheral VA ECMO A B C A. Central cannulation B. Femoral artery cannulation C. Axillary artery cannulation Journal of Thoracic Disease, Vol 7, No 7 July 2015

5 Central VA ECMO Return cannula Drainage cannula Drainage cannula: Right atrium Return cannula: Aorta Direct insertion into the mediastinal vessels Insights Imaging (2014) 5: DOI /s x

6 Peripheral Femoro-Femoral VA ECMO Drainage cannula Drainage cannula: Distal IVC or SVC Return cannula: Iliac artery Insertion of cannulas in peripheral vessels Return cannula Insights Imaging (2014) 5: DOI /s x

7 Peripheral Right Axillary Artery VA ECMO Distal perfusion cannula Return cannula Drainage cannula Drainage cannula: Distal IVC or SVC Return cannula: Right Axillary Artery Insertion of cannulas in peripheral vessels Insights Imaging (2014) 5: DOI /s x

8 Peripheral Femoro-Femoral VA ECMO Fig. 3 Veno-arterial ECMO (VA). Blood is drained from the right atrium, oxygenated and decarboxylated in the ECMO device and returned to the iliac artery towards the aorta. Note the modified position of the venous cannula tip compared to veno-venous ECMO. Cannulation of the femoral artery requires an additional sheath for perfusion of the leg downstream of the cannulation site (inset) Clin Res Cardiol (2016) 105:

9 Femoral Artery Cannulation Technique ü Direct cut down cannulation ü Percutaneous cannulation (Seldinger technique) ü Semi-Seldinger technique

10 Site of Puncture Skin-Inguinal crease 2-3 cm below the mid point of the skin crease Not a realiable marker in obese patients Bony landmarks 2-3 cm below the mid inguinal point, Between the anterior superior iliac spin and pubic tubercle Maximal femoral pulse Could result in high or low puncture (Obese patients)

11 The Ideal Site of Puncture CFA is an ideal site for arterial access because it is: ü relatively large ü less involved with atherosclerosis ü compressible against the underlying head of the femur

12 Femoral artery Puncture and Cannulation ü angle to ensure that the artery will be cannulated 2 cm superior to the skin entry site ü more vertical entry promotes kinking ü lower the hub of the needle in obese ü good pulsatile flow before any guidewire advancement

13 VA ECMO Femoral artery cannulation Aorta Fig. 3 Veno-arterial ECMO (VA). Blood is drained from the right atrium, oxygenated and decarboxylated in the ECMO device and returned to the iliac artery towards the aorta. Note the modified position of the venous cannula tip compared to veno-venous ECMO. Cannulation of the femoral artery requires an additional sheath for perfusion of the leg downstream of the cannulation site (inset) Clin Res Cardiol (2016) 105:

14 VA ECMO Femoral vein cannulation Fig. 3 Veno-arterial ECMO (VA). Blood is drained from the right atrium, oxygenated and decarboxylated in the ECMO device and returned to the iliac artery towards the aorta. Note the modified position of the venous cannula tip compared to veno-venous ECMO. Cannulation of the femoral artery requires an additional sheath for perfusion of the leg downstream of the cannulation site (inset) Clin Res Cardiol (2016) 105:

15 Cannulae tions from tip Pressure drop vs. flow for all arterial HLS cannulae Pressure drop vs. flow for all venous HLS cannulae Pressure drop [mmhg] Pressure drop [mmhg] Flow Rate l/min (H2O at ambient temperature) Flow Rate l/min (H2O at ambient temperature)

16 Order details arterial HLS cannulae: Type Outer Diameter Insertion Length Side Holes Perforation Length Connector PAS Fr. (4.3 mm) 15 cm 2 1 cm 3/8" LL PAS Fr. (5.0 mm) 15 cm 2 1 cm 3/8" LL PAS Fr. (5.7 mm) 15 cm 2 1 cm 3/8" LL PAS Fr. (6.3 mm) 15 cm 2 1 cm 3/8" LL PAS Fr. (7.0 mm) 15 cm 2 1 cm 3/8" LL PAS Fr. (7.7 mm) 15 cm 2 1 cm 3/8" LL PAL Fr. (5.0 mm) 23 cm 2 1 cm 3/8" LL PAL Fr. (5.7 mm) 23 cm 2 1 cm 3/8" LL PAL Fr. (6.3 mm) 23 cm 2 1 cm 3/8" LL PAL Fr. (7.0 mm) 23 cm 2 1 cm 3/8" LL PAL Fr. (7.7 mm) 23 cm 2 1 cm 3/8" LL One cannula per carton Order details venous HLS cannulae: Cannulae tions from tip Type Outer Diameter Insertion Length Side Holes Perforation Length Connector PVS Fr. (6.3 mm) 38 cm cm 3/8" PVS Fr. (7.0 mm) 38 cm cm 3/8" PVS Fr. (7.7 mm) 38 cm cm 3/8" PVS Fr. (8.3 mm) 38 cm cm 3/8" PVL Fr. (7.0 mm) 55 cm cm 3/8" PVL Fr. (7.7 mm) 55 cm cm 3/8" PVL Fr. (8.3 mm) 55 cm cm 3/8" PVL Fr. (9.7 mm) 55 cm cm 3/8" One cannula per carton Percutaneous Insertion Kits 4 multi-step dilators: 10/12 Fr., 12/14 Fr., 14/16 Fr., 16/18 Fr x 100 cm with J-tip guidewire for arterial cannulae x 150 cm with J-tip guidewire for venous cannulae Guidewire advancer 18 ga. puncture needle Mini scalpel blade 10 cc syringe Additional dilator sizes and guidewires available

17 Peripheral Femoro-Femoral VA ECMO Achilles heel 1. Lower Limb Ischemia 2. Harlequin Syndrome 3. Pulmonary Edema Clin Res Cardiol (2016) 105:

18 Leg ischemia - Femoral artery ECMO cannulation

19 Lower Limb Ischemia Monitoring 1. NIRS 2. Doppler imaging 3. Clinical Assesment 4. Lab Tests LIMITS ü Global state of hypoperfusion ü Continous Flow ü Vasculopathies ü Hypercoagulable state ü CK not reliable (AMI) ü TOO LATE!

20 Without Reperfusion

21 Direct cut down distal leg perfusion

22 Direct cut down distal leg perfusion 8-Fr cannula

23 Direct cut down distal leg perfusion 8-Fr cannula and 3/8 à 3/8-1/4 Connector

24 Semi-Seldinger technique

25 Semi-Seldinger technique

26 Semi-Seldinger technique

27 Percutaneous distal leg perfusion 5-Fr Introducer Sheath

28 VA ECMO Femoral artery cannulation and distal leg perfusion An arterial return cannula inserted into the right common femoral artery (RCFA) with a backflow cannula providing perfusion to the leg distal to the cannula.

29 Is Lower Limb Venous Drainage During Peripheral Extracorporeal Membrane Oxygenation Necessary? ISIDORO DI BELLA,* ENRICO RAMONI,* UBERTO DA COL,* ANGELA VIDILI, ALESSIA ROSSI,* AYIOMAMITIS MICHALIS,* AND TEMISTOCLE RAGNI* Technique to prevent limb ischemia during peripheral cannulation V Kasirajan et al. Women Long period Large Cannula Thrombosis of the Catheter maintaining adequate blood flow, as shown in Table 1. In conclusion, we believe that, in peripheral ECMO, distal venous drainage is not mandatory, although it implies a continuous clinical limb surveillance. ASAIO Journal 2010

30 Peripheral Femoro-Femoral VA ECMO: tips and tricks

31 Choice of Puncture Site

32 Anatomical landmarks

33 I STEP Distal perfusion catheter

34 II STEP Percutaneous arterial puncture guidewire placement

35 Serial dilation (Seldinger technique)

36 Arterial Cannulation

37 III STEP Percutaneous Vein puncture guidewire placement

38 Vein cannulation

39 IV STEP Start ECMO

40 Peripheral Femoro-Femoral VA ECMO Achilles heel 1. Lower Limb Ischemia 2. Harlequin Syndrome 3. Pulmonary Edema Clin Res Cardiol (2016) 105:

41 Harlequin Syndrome BLUE HEAD RED LEGS Clin Res Cardiol (2016) 105:

42 Heart against VA ECMO: Competition

43 Watershed Phenomen Ann Thorac Surg 2013;95:35

44 VA ECMO with Right Axillary Artery Advantages: ü Antegrade flow, Central ü Safe, low complication rates Disadvantage: ü More time consuming procedure ü Not percutaneously ü Direct cannulation/side grafting ü Hyperperfusion syndrome Contraindication ü Extension of aortic disease into the artery ü Known axillary/subclavian stenosis Ann Thorac Surg 2005;79:2163 5

45

46 Central VA ECMO

47 Central VA ECMO

48 Hybrid configuration VV VA VVA VV+VA VAV

49 Triple Cannulation ü an upgrade of an existing VV or VA ECMO circuit ü may either be instituted as VVA or VAV cannulation Clin Res Cardiol (2016) 105:

50 VVA configuration Fig. 5 Veno-veno-arterial ECMO (VVA). When unloading by venoarterial ECMO is not sufficient, a second draining cannula may be necessary. The draining flows from the two venous cannulas are merged outside the body using a Y-connector (inset) Clin Res Cardiol (2016) 105:

51 VAV configuration Fig. 6 Veno-arterio-venous ECMO (VAV). When circulatory support with veno-arterial ECMO is complicated by respiratory failure or when respiratory support by veno-venous ECMO is complicated by heart failure, a third cannula may be necessary. Both approaches result in one draining and two supplying cannulae. Flow through the supplying cannulae is balanced using an adjustable clamp (inset, black arrow) and a separate flow sensor (inset, white arrow) Clin Res Cardiol (2016) 105:

52 VAV configuration

53 VA VV - IMPELLA

54 Peripheral Femoro-Femoral VA ECMO Achilles heel 1. Lower Limb Ischemia 2. Harlequin Syndrome 3. Pulmonary Edema Clin Res Cardiol (2016) 105:

55 ECMO increases LV afterload A Pressure (mm Hg) Baseline CGS ECMO 1.5 L/min ECMO 3.0 L/min ECMO 4.5 L/min Volume (ml) B JACC VOL. 66, NO. 23, 2015 DECEMBER 15, 2015:

56 Pulmonary edema under peripheral ECMO

57 Management of pulmonary edema under peripheral ECMO ü ü Solutions to decrease LVEDP: Inotropes for improving LV ejection Decrease ECMO flow Intra Aortic Balloon Pump Impella ü Atrial Septostomy ü Transeptal LA drainage Switch from femoral to central ECMO (with a LA, PA or LV drainage cannula) ü B Baseline CGS RA Ao 4.5 L/min TPR 75% TPR 50% C Baseline CGS ECMO 4.5 L/min Ees 125% Ees 150% Pressure (mm Hg) Pressure (mm Hg) CGS = cardiogenic shock RA-Ao = ECMO TFR = total peripheral resistance Ees = end-systolic elastance Volume (ml) Volume (ml) JACC VOL. 66, NO. 23, 2015 DECEMBER 15, 2015: C 150

58 Management of pulmonary edema under peripheral ECMO IMPELLA

59 Tips and Tricks

60 Tips and Tricks

61 What makes cannulation difficult?

62 Severe Aortic Regurgitation

63 Mitral Valve Regurgitation

64 Aortic Dissection

65 Cannula Malposition

66 Cannula Thrombosis

67 Cardiac Tamponade

68 Kinking of distal leg cannula

69 It can also be your fault.

70 It can also be your fault. Transient Limb Ischemia re 1: Venous cannula catheter placed just distal to the bifurcation ar Figure 2: Schematic drawing of the venous cannula compressing the superficial

71 Decannulation Procedure Direct cut down cannulation: ü Vascular repair Percutaneous cannulation and Semi-Seldinger technique: ü Manual Compression following of a Mechanical Compression System ü Vascular repair ü Vascular Closure Device

72 642 ECMO and counting THANK YOU