Published in:
01-09-2020 | ECMO | Imaging in Intensive Care Medicine
A strange position of a venous drainage ECMO cannula
Published in: Intensive Care Medicine | Issue 9/2020
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Dual cannulation was performed under ultrasound guidance for venovenous ECMO in this patient with severe ARDS. A multiperforated 25F drainage cannula (MEDTRONIC Biomedicus Multistage Venous Femoral 25Fr × 60 cm) was inserted via the left femoral vein, and its tip was positioned at the entrance of the right atrium as confirmed by transesophageal echocardiography. The return cannula was inserted through right jugular access. After 10 days of uneventful ECMO run, an abdominal CT scanner was performed to identify the source of recurrent sepsis. Surprisingly, the drainage cannula was positioned on the left side of the aorta (Fig. 1a). In this patient presenting a dual inferior vena cava (IVC), the drainage cannula entered the left iliac vein, continuing into the left IVC, the left renal vein and then the common part of the IVC just before entering the thorax (Fig. 1b, c).
Fig. 1
a Transverse view of the two inferior vena cava with the ECMO drainage cannula in the left IVC. The drainage cannula was positioned in a vessel at the left side of the aorta. b ECMO cannula in left IVC terminating in the main IVC. In this patient, the dual IVC was characterized by the persistence of a left-sided IVC draining into the left renal vein which merged with some angulation the right-sided IVC just before the entrance in the thorax and right atrium. c Schematic representation of the main dual IVC variants. c Represents the actual variant that this patient presented. This variant carries a risk of perforation of renal vein at its junction with left IVC (and insertion of the drainage cannula into the retroperitoneal space) during left femoral access. d Represents the other main variant of a dual vena cava, with prolongation into an azygos vein, ultimately draining into the superior vena cava through brachiocephalic veins. In this less frequent variant, the suprarenal part of IVC is absent, and blood is drained though the azygos vein (usually left). The azygos vein is of smaller size, and this variant is at high risk of perforation at several places (junction of IVC with renal veins as well as azygos vein at any place) during either right or left femoral access
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