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At the time of publication, bedside percutaneous VA ECMO decannulations are performed exclusively with the MANTA closure device in the authors’ cardiovascular ICU. They are able to consistently deploy this device with a single attempt and achieve hemostasis with less blood loss overall than their experience with other devices.
It is important to establish which patients can be considered potential candidates for percutaneous ECMO decannulation. To assist in making this decision, the authors have created a few guidelines.
1. The patient is peripherally cannulated for VA ECMO.
2. Vascular access is obtained with ultrasound guidance.
3. There is no evidence of severe peripheral arterial disease.
4. There is no concern for cannulation site infection.
5. The patient is hemodynamically appropriate for decannulation on a turndown study.
The Surgery
To determine clinical readiness for ECMO decannulation a combination of echocardiography (transthoracic or transesophageal) and hemodynamic assessment were performed in response to a turndown trial. When the patient remained stable for decannulation following the turndown trial, a location for decannulation was selected. This can be performed either in the operating room or in the intensive care unit.
The cannulation sites were then prepped with Chloraprep solution and draped in a sterile fashion. An arterial line was connected to the distal perfusion catheter to evaluate for pulsatile flow distal to the arterial return cannula. This waveform was displayed on the monitor. Pulsatile flow was demonstrated on the waveform before deciding to proceed with percutaneous decannulation. The authors prefer to see between 5 and 10 mmHg of pulsatility with this bedside test. If there is not pulsatile flow in the DPC then the decision to proceed with percutaneous decannulation should be re-evaluated.
An ultrasound probe can be used to verify vascular access on the anterior surface of the femoral vessels. If repeat echocardiography is to be performed, it should be done at this time to monitor the patient’s hemodynamic profile while support is further turned down.
Once confirmation of readiness for separation of ECMO was complete, the circuit was clamped and the tubing along the drainage side was divided. If reinfusion of circuit volume is to be performed, it should be done at this time by connecting the drainage side tubing to a reinfusion line. It is important to monitor hemodynamic response to circuit volume infusion if this is performed.
Two figure of eight Prolene sutures were then placed around the venous access site at the skin. The cannula was then removed quickly and smoothly to minimize blood loss and pressure was applied above and below the access site while these sutures were tied.
Attention was then turned to the arterial cannula. The distal perfusion catheter was turned off to the patient. The arterial return cannula and tubing were clamped and divided. A micropuncture needle was then inserted into the non-wire reinforced portion of the return cannula. A micropuncture wire was placed through the needle and subsequently a 5 Fr micropuncture catheter was advanced over the wire.
A 0.035 in J-tip wire was then advanced through the 5 Fr micropuncture catheter and safely into the cannula and vessel. The sutures securing the return cannula to the skin were then removed and the cannula was backed out over the wire with pressure maintained at the arterial access site. The Manta depth gauge device (8 Fr or 14 Fr) was then loaded onto the wire and advanced into the artery. Blood return was noted from the indicator side port and the depth at the skin marked the arteriotomy depth. This should be confirmed with multiple passes of the device. The importance of accurately determining the arteriotomy depth cannot be overemphasized.
To select the device deployment depth, one centimeter was added to the arteriotomy depth determined by the depth gauge device. The Manta insertion sheath was then assembled with its introducer and advanced over the wire into the vessel. The introducer was removed and the Manta device, with its collagen plug, were advanced over the wire and into the sheath. The deployment device should click into place when properly inserted.
The assembled Manta device was then retracted to the predetermined device deployment depth. The footplate was then deployed by rotating the action lever and the entire device was withdrawn over the wire at a 45 degree angle. Once the footplate approximated the inner vessel wall, light tension was felt. Yellow or green was displayed in the indicator window with the development of this tension. The angle of deployment was then gradually shifted to between 60 and 80 degrees and this gentle tension was maintained. Green displayed in the indicator window equated to full deployment of the collagen plug on the outer vessel wall. The radiopaque lock could then be advanced by the blue tube over the wire and suture to secure the plug over the outer vessel wall. This can be gently moved back and forth to assess for hemostasis.
Once hemostasis was achieved, the wire was removed and the suture was trimmed beneath the level of the skin. The distal perfusion catheter was then removed over a wire and an Angioseal device was used to close the arteriotomy site. If the vessel is small or there are concerns about Angioseal deployment, the distal perfusion catheter can be removed and direct pressure maintained at the site until hemostasis is achieved. Lower extremity arterial and venous duplex studies were obtained 48 hours after decannulation.
References
- Pasrija C, Bernstein DA, Rice M, Tran D, Morales D, Grintz T, Deatrick KB, Gammie JS, Madathil R, Kaczorowski DJ. Sutureless Closure of Arterial Cannulation Sites. Innovations (Phila). 2020 Mar/Apr;15(2):138-141. doi: 10.1177/1556984519899940. Epub 2020 Feb 28. PMID: 32107959.
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