Vascular Access &

Cannulation

Dr Osama Bawazir
Assistant Professor , Consultant Pediatric surgeon
FRCSI, FRCS(Ed), FRCS (glas), FRCSC,
FAAP,FACS.

 ECMO is a supportive measure, which

can be instituted as an urgent, semi
elective or elective procedure

Time in relation to the event is the

limiting factor when going through the
assessment cascade in order to
accomplish a successful result

Introduction
PRE-ECMO ASSESSMENT
CANNULATION
INITIATION AND MAINTENANCE OF
ECMO
EVALUATION

CANNULATION
The establishment and
maintenance of
adequate vascular
access is essential
for ECMO

CANNULATION
- Patient age and size
- Underlying disease &
condition
- Cause of the cardiorespiratory
compromise
- Type of support:
Veno-venous (VV) ECMO
Veno-arterial (VA) ECMO

- Time of the event in relation to

the peri-operative period
- Location

CANNULATION
For each modality, there are
different kinds and sizes of
cannulae that can be used
Target activated clotting time
(ACT) should be
accomplished first before
ECMO (heparin 100 units/kg)
3 minutes before cannulation.
Consent
GA

Guidelines for Cannula size

Weight (Kg)

Venous cannula arterial cannula

2-4

8-14

8-10

5-15

15-19

12-15

16-20

19-21

15-17

21-35

21-23

17-19

35-60

23

19-21

>60

23

21

Poiseuilles Law
Poiseuille's law: In an
artificial system, flow
through a cylindrical tube
or any segment of a tube is
directly proportional to P,
the driving pressure along
the tube, and the fourth
power of the radius, r. Flow
is inversely proportional to
L the length of the
segment and to , the
viscosity of the liquid. The
proportionality constant is
/8.

Cannula Consideration
Venous cannula should be with the largest
lumen and shortest length possible
(gravity).
Venous cannula should have side holes.
M-number
Resist kinking
The smallest double lumen cannula is size
12 F ( for V V ecmo in neonate)

CANNULATION
Veno-Venous (V-V) ECMO
- Mainly used for respiratory
support (ARDS & Congenital
Diaphragmatic Hernia)
- V-V ECMO provides adequate
oxygenation and CO2
removal
- The venous access can be
established by using the
system in one site, or two
different sites

CANNULATION
Veno-Arterial (VA)
ECMO
provides cardiac as
well as respiratory
support and is mainly
used for post op
cardiac case

(V-V) ECMO Advantage offer

(V-A) ECMO
Eliminate the potential for arterial
embolization and ischemia
Arterial ligation or repair is unnecessary
Improve the blood flow and oxygenation to
pulmonary circulation.
No hemodynamic effects

CANNULATION TECHNIQUE
Open
Semi-open
Percutaneous

CANNULATION
Internal jugular vein

CANNULATION

Subclavian vein &

Right atrium

CANNULATION

Femoral vein

CANNULATION
One site
- A double lumen cannula is
inserted into the internal
jugular vein
- Only one site for venous
access

CANNULATION

Two different sites

CANNULATION
Veno-Arterial (VA) ECMO
provides cardiac as well as
respiratory support and is
mainly used for post op
cardiac case

CANNULATION
Internal jugular vein
and the common
carotid artery

CANNULATION

Right atrium and

ascending aorta

CANNULATION

Femoral vein and

artery

CANNULATION

A Left atrial pressure

line can be utilized to
monitor the LA
pressure

CANNULATION
In situations where ECMO
support is anticipated
- Chest will be left open
and covered by a Silastic
patch
- Purse-string sutures will
be left snared in place
- Standby preprimed pump
will be kept in ICU

CANNULATION PROBLEMS
Threading the venous
catheter
Vein division
Proximal vein lost in
mediastinum
Lack of venous return
Intrathoracic vein
perforation

Complication
Vascular injury( tear,
intimal dissection,
perforation).
Obstruction (kinking,
positional).
Misplacement( AI,
afterload LV failure).
Bleeding.
Recirculation.

Thank You