Ann Thorac Surg 2006;81:1514-1516
© 2006 The Society of Thoracic Surgeons
Case report
Extracorporeal Membrane Oxygenation Support of a Neonate with Percutaneous Femoral Arterial Cannulation
Karen L. Booth, MD
a
,
b
,
*
,
Kristine J. Guleserian, MD
a
,
b
,
John E. Mayer, MD
a
,
b
,
Peter C. Laussen, BBS
a
,
b
a Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA
b Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA
Accepted for publication February 22, 2005.
* Address correspondence to Dr Booth, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115 (Email: karen.booth{at}cardio.chboston.org).
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Abstract
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We describe a neonate with hypoplastic left heart syndrome supported with venoarterial extracorporeal membrane oxygenation with a femoral arterial cannula. A 6-French straight sheath was percutaneously placed in the right femoral artery using the Seldinger technique. Adequate extracorporeal membrane oxygenation flows were achieved, and the patient was successfully de-cannulated. Femoral arterial cannulation in neonates is technically feasible and provides an alternative site for extracorporeal membrane oxygenation cannulation.
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Introduction
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Extracorporeal membrane oxygenation (ECMO) is an important mechanical support for infants and children with both circulatory and respiratory failure. Sites and techniques of cannulation of major vessels for ECMO have varied based on the indication for cannulation [1]. Neonates with respiratory failure are often cannulated using a surgical cutdown approach of the right internal jugular vein and carotid artery. Cannulation of postoperative cardiac patients is typically accomplished through an existing sternotomy with direct right atrial and ascending aortic cannulation. Alternatively, open or percutaneous femoral cannulation has been used. Previous reports of femoral cannulation have been limited to older children and adults [2, 3]. Likely this has been due to concerns of limitation of cannulation size and inability to maintain adequate ECMO flows in infants. Here we report the successful percutaneous right femoral arterial cannulation in a neonate.
A 3.4 kg neonate with hypoplastic left heart syndrome and intact atrial septum presented with severe cyanosis. She was stabilized with left atrial decompression with balloon atrial septostomy in the catheterization laboratory. She subsequently underwent stage 1 palliation with a 3.5-mm Blalock-Taussig shunt. Postoperatively, the patient's course was notable for frequent episodes of cyanosis. Serial chest roentgenogram revealed a persistent pattern of pulmonary venous congestion. She was urgently reintubated for progressive hypoxia. During intubation, she had bradycardia develop that progressed to cardiopulmonary arrest. She was cannulated onto venoarterial ECMO through her right carotid artery and right internal jugular vein with our rapid response ECMO protocol [4]. After cannulation she was taken to the cardiac catheterization laboratory where an angiography revealed an aberrant right subclavian artery and revealed that her shunt was in fact anastomosed to her right common carotid artery. The right carotid arterial ECMO cannula was partially occluding her proximal shunt origin (Fig 1). Her pulmonary veins were very hypoplastic and the cause of her arrest was believed to be pulmonary hypertensive crisis from pulmonary venous obstruction. Because of the shunt obstruction, it was necessary to remove her right carotid arterial cannula in order to adequately support and wean her from ECMO.
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Fig 1. This angiogram demonstrates the arterial cannula traversing the origin of the Blalock-Taussig (BT) shunt, thus compromising pulmonary blood flow. (RV = right ventricle.)
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The small 3-French femoral arterial sheath that had been inserted for catheterization was upsized to a 6-French 13-cm straight sheath (Desilets-Hoffman Flexor Introducer Set, Cook, Bloomington, IN). This sheath is mounted over a dilator that accepts a guidewire for percutaneous placement with the Seldinger technique (Fig 2). Distal perfusion to the right foot was preserved with normal capillary refill time, although distal pulses were not palpable. The arterial limb of the circuit was transferred to the new right femoral arterial cannula and ECMO flows were maintained at 350 to 430 cc/min. The connection between the luer-lock end of the cannula and the ECMO circuit was made with a perfusion adapter (DLP-10007, Medtronic, Minneapolis, MN) (Fig 2). There was no change in measured post-membrane pressure that would have indicated high resistance through the 6-French arterial cannula. At hour 140, she was successfully de-cannulated from ECMO. The removal of the right femoral arterial cannula was complicated by transient adherence of the cannula to the arterial intima, but the cannula was successfully removed with an intact artery and distal pulse. The patient was subsequently extubated and discharged home on nasal cannula oxygen and sildenifil for her pulmonary hypertension.
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Fig 2. The 6-French arterial cannula connection to the extracorporeal membrane oxygenation (ECMO) tubing with a perfusion adapter (DLP-100007, Medtronic, Minneapolis, MN) is shown (above). The 6-French arterial cannula with dilator in place is shown (below).
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Comment
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This case report supports the feasibility of percutaneous femoral ECMO cannulation in a neonate using a small caliber arterial cannula. Although the neck is the preferred cannulation site in neonates and small infants, there are circumstances such as the one described in this report when such an approach is less desirable. Femoral access should be considered if the access to the carotid artery is technically impossible or complications are encountered during neck cannulation [5]. In an emergent situation such as cannulation during a cardiopulmonary arrest, femoral cannulation may be more expeditious as it does not require a surgical cutdown access of the vessel [2]. Percutaneous femoral cannulation may be the ideal approach when these vessels have already been accessed during cardiac catheterization [3], or as an alternative to cannulation through an open sternotomy in a postoperative patient to reduce the risk of bleeding and infection [6].
Previous literature has suggested that the optimal size of arterial cannulae in neonates is at least 8-French or 10-French, based on flow characteristics [7, 8]. Our patient was successfully supported with a 6-French arterial cannula, and we were able to maintain flows as high as 125 cc/kg/min without hemolysis or excessive post-membrane pressures. Our success with this technique may be due to the geometry of this newer cannula designed for percutaneous femoral cannulation (Desilets-Hoffman Flexor Introducer Set, Cook, Bloomington, IN). The internal diameter of this 6-French cannula is 2.03 mm, which is comparable with the internal diameter of the 8-French arterial cannulas (1.90 mm to 2.26 mm) as previously described [7]. The length of the cannula (13 cm) is also comparable with older cannulas that range from 7.5 cm to 16 cm. Therefore, these newer cannulas may increase the flexibility of cannulation sites because the flow dynamics are similar, despite the smaller external diameter and French size.
In conclusion, percutaneous femoral cannulation of neonates for ECMO is technically feasible, and in certain clinical circumstances it may be the more desired site for cannula placement.
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References
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Abstract
Introduction
