Aug 2026· Journal of Visualized Experiments· Vol 234· 0 citations
Medicine
TL;DR
This protocol provides a practical, evidence-based approach for ultrasound-guided peripheral VA-ECMO cannulation and focuses specifically on vascular access and cannulation rather than broader VA-ECMO management.
Abstract
Point-of-care ultrasound (POCUS) has become an important imaging modality for guiding peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation. This protocol describes the integration of POCUS throughout the peripheral VA-ECMO cannulation workflow, including pre-procedural assessment, real-time procedural guidance, and post-cannulation verification. During the pre-procedural assessment, POCUS facilitates differentiation of arteries from veins, measurement of vessel diameter to estimate appropriate cannula size, and identification of vascular pathology, including plaques, thrombosis, and stenosis. During cannulation, combined out-of-plane and in-plane ultrasound techniques enable real-time visualization of the guidewire, confirmation of guidewire placement within the target vessel, and avoidance of posterior wall perforation or injury to adjacent structures. Following cannulation, POCUS is used to verify drainage cannula positioning at the inferior vena cava-right atrium junction and arterial return cannula positioning at the external or common iliac artery level, and to assess for complications such as cardiac tamponade, cannula malposition, and thrombosis. Compared with landmark-based or fluoroscopy-guided techniques, POCUS provides bedside imaging without ionizing radiation and supports continuous procedural guidance without interrupting resuscitation. This protocol provides a practical, evidence-based approach for ultrasound-guided peripheral VA-ECMO cannulation and focuses specifically on vascular access and cannulation rather than broader VA-ECMO management.
Autonomous or semi‑autonomous "autonomous vascular access" (AVA) platforms have the promise to standardize technique, accelerate placement by a wider range of providers, extend cannulation capability to austere settings, and reduce complication‑related morbidity.
Joel Grunhut, Patrick Walker, Meredith Lackie et al.· Military Medicine· 0 citations
PURPOSE
To describe the ECO-PLUG technique, a standardised ultrasound-guided workflow for percutaneous femoral access and plug-based closure, and to report its feasibility and clinical performance in patients undergoing peripheral artery revascularization procedures.
TECHNIQUE
The ECO-PLUG protocol incorporates continuous ultrasound guidance throughout all procedural phases: femoral access, closure device deployment, and post-procedural haemostasis verification. Five predefined checkpoints (C1-C5) structure the workflow from pre-access mapping to early and delayed ultrasound follow-up. Key elements include in-plane puncture, ultrasound-guided plug deployment with a modified retract manoeuvre, and systematic colour-Doppler assessment at 0 and 3 to 5 minutes after closure.
RESULTS
A total of 200 elective endovascular procedures using 6F/8F femoral access were analysed. Anatomical complexity was common, including moderate-to-severe anterior wall calcification (55%), arterial depth >35 mm (24%), and bifurcation variants (22%). Immediate haemostasis was achieved in 98% of cases, while 2% required prolonged compression or manual conversion. Access-related complications occurred in 4% of patients, including pseudoaneurysms (1.5%) and haematomas. No arterial occlusions or surgical conversions were observed.
CONCLUSIONS
The ECO-PLUG protocol demonstrates acceptable haemostasis efficacy and a favourable access-site safety profile across anatomically complex settings, supporting its potential as a structured image-guided closure strategy. Prospective comparative studies are needed to validate these preliminary findings.Clinical ImpactThe ECO-PLUG protocol introduces the first formally structured, checkpoint-based ultrasound workflow integrating continuous imaging guidance across all phases of percutaneous femoral closure, from pre-access mapping through plug deployment and hemostasis verification. Unlike conventional approaches, where ultrasound use is typically limited to arterial puncture alone, ECO-PLUG extends real-time sonographic control to anchor positioning and collagen release, reducing operator dependency in anatomically complex cases. With 98% immediate hemostasis and no arterial occlusions or surgical conversions across 200 consecutive procedures, including patients with heavy calcification, deep vessels, and bifurcation variants, this protocol offers clinicians a reproducible, teachable standard applicable across varying experience levels.
E. Pasqui, Leonardo Pasquetti, M. Anzaldi et al.· Journal of Endovascular Ther...· 0 citations
Background
Rapid central venous access is essential in the management of cardiogenic shock. Although ultrasound-guided internal jugular vein cannulation is widely recommended, landmark-guided subclavian venous access remains necessary during emergency resuscitation when ultrasound guidance is not feasible. The optimal laterality for landmark-guided subclavian cannulation remains uncertain.
Objectives
Our Objectives are to compare the incidence of catheter malposition and complications between left- and right-sided landmark-guided subclavian venous cannulation in critically ill patients with cardiogenic shock in the coronary care unit.
Methods
We conducted a retrospective cohort study including 150 adult patients who underwent emergent landmark-guided subclavian venous catheterization in the coronary care unit. The primary outcome was catheter malposition confirmed by post-procedure chest radiography. Secondary outcomes included pneumothorax, arterial puncture, and hematoma formation.
Results
Among 150 patients, 72 underwent left-sided cannulation and 78 underwent right-sided cannulation. Catheter malposition occurred significantly more frequently following right-sided cannulation compared with left-sided cannulation (12.8% vs 2.8%; p = 0.03), corresponding to an approximately 4.6-fold higher risk of malposition. Mechanical complication rates were low and did not differ significantly between groups.
Conclusions
Right-sided landmark-guided subclavian cannulation was associated with a higher incidence of catheter malposition compared with the left-sided approach. The anatomical course of the left brachiocephalic vein may facilitate more reliable catheter placement during emergency central venous access.
Swe Min Oo, Myint Zaw, Tun Naing Oo et al.· International Journal of Med...· 0 citations
Critical limb ischemia (CLI) secondary to femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a recognized and morbid complication, with an incidence reaching 25.4% when prophylactic distal perfusion catheter (DPC) placement is omitted at cannulation. We report the case of a 77-year-old male [height 170 cm, weight 62 kg, body surface area (BSA) 1.72 m2] with long QT syndrome (LQTS), dilated cardiomyopathy, and a recent mitral valve replacement who developed refractory cardiogenic shock and electrical storm in the postoperative period, requiring VA-ECMO support via femoro-femoral cannulation. Progressive CLI of the right lower limb was confirmed by duplex Doppler ultrasound on day 8 of extracorporeal support, demonstrating occlusive thrombosis at the popliteal level with near-absent infrapopliteal flow. The limb was classified as Society for Vascular Surgery (SVS) Class IIb (immediately threatened). Emergency surgical intervention included Fogarty thrombectomy and femoro-popliteal bypass with a 6 mm ringed Propaten graft. The novel technical element was the direct coupling of the VA-ECMO arterial perfusion cannula to the prosthetic anastomosis via a three-way Luer-lock stopcock, providing dual-source distal perfusion without requiring an independent perfusion catheter. Immediate limb perfusion was restored and confirmed intraoperatively. The patient subsequently died from refractory cardiogenic shock attributed to irreversible cardiac failure, precluding assessment of durable functional limb outcome. This case documents an innovative surgical strategy for refractory VA-ECMO-related CLI that may serve as a technical reference when standard distal perfusion strategies are insufficient.
Rafael E. Castellar Martinez, Maria C. Urina Cabas, Andres C. Castellar Martinez et al.· Frontiers in Cardiovascular...· 0 citations
Acute limb ischemia (ALI) is a serious complication of femoral artery cannulation during peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), with reported incidence rates approaching 17%. Although several contributing factors have been described, the fundamental problem is reduced arterial flow distal to the cannulation site, often worsened by systemic vasoconstriction. Distal perfusion catheters (DPC) are the most widely used strategy to prevent this, but the optimal device, technique, and timing remain uncertain due to limited evidence. Early detection with near-infrared spectroscopy, along with emerging approaches such as bidirectional cannulas and artificial intelligence-based prediction tools, may improve prevention and management. This narrative review brings together current evidence on ALI in peripheral VA-ECMO and places particular emphasis on contemporary techniques for DPC placement with practical monitoring.
Nupur Karan, Rohit Patnaik, S. Pattanaik et al.· World Journal of Critical Ca...· 0 citations
ABSTRACT INTRODUCTION Femoral venous cannulation is widely used to establish cardiopulmonary bypass (CPB) during minimally invasive cardiac surgery (MICS). Although transesophageal echocardiography (TEE) is commonly used to guide cannula placement, cannula malposition can still occur, and preserved venous drainage may delay the recognition of cardiac injury. We report a rare case of right ventricular perforation caused by femoral venous cannulation during minimally invasive aortic valve replacement (AVR), emphasizing that adequate venous drainage does not exclude cannula malposition or cardiac perforation. CASE PRESENTATION A 79-year-old man with severe aortic stenosis underwent minimally invasive AVR via a right mini-thoracotomy. Venous drainage was established via the right femoral vein using a 25-Fr, 55-cm HLS venous cannula with 24 side holes (BE-PVL 2555; Maquet Cardiopulmonary, Rastatt, Germany) under transesophageal echocardiographic guidance. Vacuum-assisted venous drainage was used. The guidewire was advanced toward the superior vena cava, and the cannula tip was initially considered to be positioned within the right atrium. After CPB was initiated, venous drainage became insufficient. The cannula was advanced blindly by approximately 2 cm, after which venous return improved. The valve procedure was completed uneventfully; however, pericardial bleeding became evident during volume loading before weaning from CPB. Conversion to median sternotomy revealed that the cannula had perforated the anterior free wall of the right ventricle and protruded into the pericardial cavity. The injury was repaired with a pledgeted mattress suture, and the patient recovered without further complications. CONCLUSIONS Adequate venous drainage during CPB does not confirm correct femoral venous cannula positioning. When venous drainage is inadequate during MICS, blind advancement of the femoral venous cannula should be avoided, and cannula position should be reassessed using multiple modalities, including TEE and fluoroscopy, when available.
K. Oue, Moe Kinoshita, Shintaro Okuda et al.· Surgery Case Reports· 0 citations
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