Avalon Elite Bicaval Dual Lumen Research Articles

Bedside repositioning of a migrated avalon ECMO cannula in an infant: Novel technique.

Background: Although the Avalon Elite bi-caval dual lumen catheter for veno-venous extracorporeal membranous oxygenation (ECMO) has many advantages, it requires precise positioning and dislodgement is common.Case presentation: A 2-year-old male was placed on ECMO due to respiratory failure utilizing a 20 Fr Avalon Elite bi-caval dual lumen catheter (AEC). The AEC migrated twice with unsuccessful repositioning using the classic manual manipulations. The AEC was successfully repositioned on the two occasions using a novel method by direct access of the ECMO inflow tube using a combination of catheter and guide wire.Conclusions: A migrated AEC could be successfully repositioned with simple direct access of the inflow tube. This technique was successfully utilized twice at the bedside in an infant without needing additional venous access.

Reposition of a Bi-caval Dual Lumen ECMO cannula using a trans-femoral lasso

Abstract Veno-venous double lumen Extracorporeal membrane oxygenation (VVDL-ECMO) in neonates and infants for viral pneumonia is a well-established therapy. However even after initial correct positioning of the VVDL-ECMO cannula, there is a risk of unexpected malpositioning of this cannula during the ECMO run. We report a case of reposition of a 16-French Avalon Elite Bi-caval Dual Lumen cannula from its malposition in the right atrium to its correct position in the inferior venous cava. The procedure was achieved by interventional catheter techniques using a goose neck snare and was done without ECMO-flow interruption.

Impact of cannula size and line length on venous line pressure in pediatric VA-/VV-ECLS circuits.

The objective of this study was to do an in vitro evaluation of venous line pressure using different venous line lengths and venous cannula sizes in pediatric venoarterial extracorporeal life support (VA-ECLS) and venovenous ECLS (VV-ECLS) circuits. The pediatric VA-ECLS circuit consisted of a Xenios i-cor diagonal pump, a Maquet Quadrox-i pediatric oxygenator, a Medtronic Biomedicus arterial cannula, a Biomedicus venous cannula, and 1/4″ ID arterial and venous tubing. The pediatric VV-ECLS circuit was similar, except it included a Maquet Avalon ELITE bi-caval dual lumen cannula. Circuits were primed with lactated Ringer's solution and packed red blood cells (hematocrit 40%). Trials were conducted at various flow rates (VA-ECLS: 250-1250mL/min, VV-ECLS: 250-2000mL/min) using different venous tubing lengths (2, 4, and 6 feet) and cannula sizes (VA-ECLS: A8Fr/V10Fr, A10Fr/V12Fr and A12Fr/V14Fr, VV-ECLS: 13Fr, 16Fr, 19Fr, 20Fr and 23Fr) at 36°C. Real-time pressure and flow data were recorded for analysis. The use of a small-caliber venous cannula significantly increased the venous line pressure in the 2 pediatric circuits (P<0.01). Shorter venous tubing lengths significantly reduced the venous line pressure at high flow rates (P<0.01). The VV-ECLS circuit had larger negative pre-pump pressure drops (7.2 to -102.2mmHg) when compared to the VA-ECLS circuit (0.7 to -60.7mmHg). Selecting an appropriate venous cannula and a shorter venous tubing when feasible may significantly reduce the pressure drop of the venous line in pediatric VA-ECLS and VV-ECLS circuits and improve venous drainage.

Hemodynamic Evaluation of Avalon Elite Bi‐Caval Dual Lumen Cannulas and Femoral Arterial Cannulas

Translational research is a useful tool to provide scientific evidence for cannula selection during extracorporeal life support (ECLS). The objective of this study was to evaluate four Avalon Elite bi-caval dual lumen cannulas and nine femoral arterial cannulas in terms of flow range, circuit pressure, pressure drop, and hemodynamic energy transmission in a simulated adult ECLS model. A veno-venous ECLS circuit was used to evaluate four Avalon Elite bi-caval dual lumen cannulas (20, 23, 27, and 31 Fr), and a veno-arterial ECLS circuit was used to evaluate nine femoral arterial cannulas (15, 17, 19, 21, and 23 Fr). The two circuits included a Rotaflow centrifugal pump, a Quadrox-D adult oxygenator, and 3/8 in ID tubing for arterial and venous lines. The circuits were primed with lactated Ringer's solution and packed human red blood cells (hematocrit 40%). Trials were conducted at rotational speeds from 1000 to 5000RPM (250rpm increments) for each Avalon cannula, and at different flow rates (0.5-7L/min) for each femoral arterial cannula. Real-time pressure and flow data were recorded for analysis. Small caliber cannulas created higher circuit pressures, higher pressure drops and higher M-numbers compared with large ones. The inflow side of Avalon dual lumen cannula had a significantly higher pressure drop than the outflow side (inflow vs. outflow: 20 Fr-100.2 vs. 49.2 mmHg at 1.1L/min, 23 Fr-93.7 vs. 41.4 mmHg at 1.6 L/min, 27 Fr-102.3 vs. 42.8 mmHg at 2.6L/min, 31 Fr-98.1 vs. 44.7mmHg at 3.8L/min). There was more hemodynamic energy lost in the veno-arterial ECLS circuit using small cannulas compared to larger ones (17 Fr vs. 19 Fr vs. 21 Fr at 4L/min-Medtronic: 71.0 vs. 64.8 vs. 60.9%; Maquet: 71.4 vs. 65.6 vs. 62.0%). Medtronic femoral arterial cannulas had lower pressure drops (Medtronic vs. Maquet at 4L/min: 17 Fr-121.7 vs. 125.0 mmHg, 19 Fr-71.2 vs. 73.7 mmHg, 21 Fr-42.9 vs. 47.4 mmHg) and hemodynamic energy losses (Medtronic vs. Maquet at 4L/min: 17 Fr-43.6 vs. 44.4%, 19 Fr-31.0 vs. 31.4%, 21 Fr-20.8 vs. 22.4%) at high flow rates when compared with the Maquet cannulae. The results for this study provided valuable hemodynamic characteristics of all evaluated adult cannulas with human blood in order to guide ECLS cannula selection in clinical practice. Use of larger cannulas are suggested for VV- and VA-ECLS.

A case of avalon cannula malposition and successful conversion to V-A ECMO in a neonate

The Avalon Elite Bi-caval Dual Lumen cannula was designed for placement in the right internal jugular vein for veno-venous double lumen extracorporeal membrane oxygenation (VVDL ECMO). Despite the use of echocardiography, it is often difficult to correctly position the VVDL cannula in neonates due to patient size and anatomy. Cannula malposition may contribute to inadequate hemodynamic support necessitating conversion to veno-arterial (V-A) support. We report a case of successful conversion from VVDL ECMO to V-A ECMO using the 13-French Avalon cannula in a neonate. This case demonstrates that the 13 French-Avalon Elite Bi-caval Dual Lumen Cannula can be safely used as a venous cannula in neonates requiring conversion to V-A ECMO.

Optimal Endovascular Methods for Placement of Bicaval Dual-Lumen Cannulae for Venovenous Extracorporeal Membrane Oxygenation

Early mobility is associated with improved outcomes in critically ill patients with acute respiratory failure. The Avalon Elite Bicaval Dual-Lumen cannula provides support for extracorporeal membrane oxygenation through a single cannula in the internal jugular position in the neck, avoiding femoral cannulation. This allows the patient to participate in early mobility and strength exercises, facilitating early reconditioning. Placement of the Avalon bicaval cannula poses a potential risk of intracardiac placement and right ventricular rupture as a result of the flexibility of the guidewire. We present our endovascular technique for Avalon bicaval cannula placement with fluoroscopic guidance to prevent inadvertent intracardiac placement.

Myocardial infarction due to malposition of ECMO cannula

Dear Editor, The most reported complications of veno-venous extracorporal membrane oxygenation (ECMO) are bleeding and infections [1]. Recently, a double lumen cannula was introduced, making introduction of two separated cannulas unnecessary. This single cannula is inserted via the right internal jugular vein and positioned with the tip resting in the inferior vena cava. Through ports in the superior and inferior caval veins, blood is returned directly into the right atrium. There have been reports describing ambulatory patients on veno-venous ECMO [2] with this type of cannula. To date, only “minor” complications have been described such as displacement of the cannula tip from the inferior vena cava into the right atrium [3]. Here we describe a case of a displaced Avalon double lumen cannula, which caused compression of the right coronary artery, 14 days after initiation of ECMO. A 61-year-old (height 1.80 m) man suffering from severe H1N1 pneumonitis for 4 days was referred to our tertiary center for ECMO. One day after admission at our center, a 27-Fr Avalon Elite bi-caval dual lumen catheter (Avalon Laboratories, Rancho Dominguez, CA, USA) was percutaneously inserted into the right jugular vein under fluoroscopy. With the catheter fully inserted, fluoroscopy showed that the tip just reached the inferior vena cava. The first X-ray confirmed this correct position. On the third day, X-ray showed that the ECMO cannula projected into the right atrium. Many attempts to reposition the cannula under fluoroscopic control failed to obtain a stable position. The team therefore had to accept the position of the tip in the right atrium. On the 14th ECMO day, cardiac markers were elevated. Echocardiography showed septal and inferior wall motion abnormalities and that the tip of the cannula was in the right atrium without crossing the tricuspid valve. On the suspicion of acute myocardial infarction, emergency coronary angiography was performed. Coronary angiography showed occlusion of the right coronary artery due to compression by the ECMO cannula (see electronic supplement: angiography in two directions). The suggested anatomic location of the compression of the right coronary artery is marked in Fig. 1. Withdrawal of the cannula resulted in a good coronary flow and after many attempts the tip of the cannula was placed in the inferior vena cava. On the 21st day, the patient was successfully weaned from the ECMO. On the 23rd day, the patient was transferred back to the referring hospital. Right ventricular function was normal and due to hypokinesia in the inferior segments; left ventricular function was moderate. Six months after hospital discharge, he had made an excellent recovery. Fig. 1 Three-dimensional computed tomography of the right atrium and right ventricle of the heart of a healthy subject (not the described patient). Note the right coronary artery (RCA) traveling on the epicardium between the right atrium and right ventricle. ... We conclude that when the cannula is short in relation to patient anatomy, misplacement of the cannula can easily occur and this could have serious complications.

Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation

Placement of the Avalon Elite bicaval dual lumen cannula for venovenous extracorporeal membrane oxygenation (VV-ECMO) via the internal jugular vein requires precise positioning of the cannula tip in the inferior vena cava with echocardiography or fluoroscopy guidance. Correct guidewire placement is clearly the key first step in assuring proper advancement of the cannula. We report a case of unexpected wire migration into the right ventricle at the time of final cannula advancement, resulting in right ventricular rupture and tamponade. Transesophageal echocardiography is an important monitoring modality for appropriate placement of the VV-ECMO guidewire and Avalon cannula, and in particular, for early identification of potential complications.

Ease of Conversion from Venovenous Extracorporeal Membrane Oxygenation to Cardiopulmonary Bypass and Venoarterial Extracorporeal Membrane Oxygenation with a Bicaval Dual Lumen Catheter

Extracorporeal circulatory support revolutionized the field of cardiothoracic surgery, initially in the form of cardiopulmonary bypass (CPB) and then in its modified form, extracorporeal membrane oxygenation (ECMO). Although initial cannulation techniques involved open intrathoracic approaches, the increased prevalence of reoperative sternotomies and the emergence of minimally invasive surgery encouraged the development of peripheral cannulation methods and configurations. The Avalon Elite Bicaval Dual Lumen catheter (Avalon Laboratories, LLC, CA) can be placed in the right internal jugular vein to provide venovenous (VV) ECMO. However, some patients on VV ECMO then develop compromised cardiac performance. We describe two ways in which the Avalon Elite was used, first for complete venous drainage through a single peripheral site for CPB and in the other to convert a patient on VV ECMO to axillary artery venoarterial (VA) ECMO.

Insertion of Bicaval Dual Lumen Extracorporeal Membrane Oxygenation Catheter with Image Guidance

Correct placement of the Avalon Elite Bicaval Dual Lumen catheter (Avalon Laboratories, LLC, CA) for single-site venovenous extracorporeal membrane oxygenation (VV ECMO) is safe using image guidance. Using this technique, 26 of 27 patients (96%) had uneventful placement of the cannula in the right internal jugular vein. One patient had a superior vena cava injury during serial dilation, and another patient required cannula repositioning for improved flows. We recommend using both fluoroscopy and transesophageal echocardiogram (TEE) for training purposes or during initial use of the Avalon Elite. As proficiency improves, TEE at the bedside provides an excellent standard of care. Double-lumen ECMO catheters can be effectively placed under image guidance with minimal need for repositioning.

Initial Experience With Single Cannulation for Venovenous Extracorporeal Oxygenation in Adults

Historically, venovenous extracorporeal membrane oxygenation has required dual cannulation. A single-venous cannulation strategy may facilitate implantation and patient mobilization. Here we present our early experience with a single cannulation technique. Review of venovenous extracorporeal membrane oxygenation support using internal jugular vein insertion of the Avalon elite bicaval dual lumen catheter (Avalon Laboratories, Rancho Dominguez, CA) in 11 consecutive patients with severe respiratory failure. Adequate oxygenation was obtained in all patients: 115 mm Hg PaO(2) (median), 53 to 401 mm Hg (range). Median time of support was 78 hours (range, 3 to 267 hours). No mortality was directly related to the cannulation strategy. There were three nonfatal cannulation-related events. Two patients had proximal cannula displacement requiring repositioning. One patient suffered an acute thrombosis of the cannula. Our series supports single-venous cannulation in venovenous extracorporeal membrane oxygenation as a promising technique. It may be an excellent alternative to current cannulation strategies in patients requiring prolonged support and specifically for those considered for a bridge-to-lung transplantation.