Surgical Cut-down and Semi-Seldinger Technique for Accurately Placing Distal Perfusion Cannula after Percutaneous Placement of Arterial Return Cannula in VA ECMO: Our Experience

Background: Extracorporeal membrane oxygenation has become a revolutionary technology for cardiorespiratory failure refractory to conventional management.Percutaneous placement of the femoral arterial cannula is preferred as a less invasive and faster technique, but it may lead to cannulation-related limb complications in 10-70% of cases.A distal perfusion cannula (DPC) is usually obtained before placing the main arterial cannula to preserve distal limb perfusion.However, it can be challenging after main arterial cannulation, especially when the patient is in shock.We aimed to compare the technical benefits and time consumed for cannulating the distal perfusing artery by surgical dissection and the Semi-Seldinger technique under direct vision in difficult cases while also looking for possible periprocedural complications.Materials and methods: After unsuccessful attempts for anterograde placement of guide wire via superficial femoral artery (SFA) under USG-guidance; the ECMO physician would directly proceed with percutaneous placement of arterial return cannula at common femoral artery (CFA) and ECLS would be initiated.The vascular surgeon would be called to dissect SFA and cannulate using a 6-8 Fr distal perfusion sheath by Semi-Seldinger technique under direct vision within 1-2 hours of arterial cannulation.The side arm of the sheath was connected to the side port of the arterial cannula after de-airing and maintained flow at 150-200 mL/min.In the subsequent hours, distal perfusion was checked by clinical examination of the limb viz.warmth, color change, stiffness of the joints and Doppler assessment of the arterial system of lower limbs.Results: In 17 cases where the ECMO physician failed to place a DPC; arterial cannulation and ECMO initiation were delayed by approximately 15-30 minutes, respectively.The surgeon took less than 15 minutes to dissect the SFA, and cannulated under direct vision within 5 minutes, and achieved distal limb perfusion in 20 seconds without any surgical complications like bleeding, hematoma or infection.Conclusion: Thus, in instances where the patient is in circulatory shock and needs an urgent ECLS with difficult vascular access, primary arterial cannulation and ECLS initiation, followed by surgical exploration of SFA, and Semi-Seldinger technique of cannulation for distal perfusion, can be tried with minimal ischemic and vascular complications.