Bilateral Internal Jugular Access for Infant Venovenous Extracorporeal Membrane Oxygenation: A Novel “Cannulation X-sign” Approach

Background: Venovenous extracorporeal membrane oxygenation (VV-ECMO) in infants presents unique technical challenges due to small vessel size and limited cannulation options.Traditional approaches involve femoral-jugular configurations or single dual-lumen cannulas, which may be unfeasible in certain clinical scenarios.Case presentation: We describe two infants requiring VV-ECMO for refractory viral respiratory failure.In both cases, Dual single-lumen cannulas were inserted via the right and left internal jugular veins (IJVs) under ultrasound guidance.Cannula positioning was confirmed radiographically.In case 1, ECMO support was successful, with stable flows, effective oxygenation, and uneventful decannulation.In case 2, despite adequate ECMO flows, the patient died from multiorgan failure.Discussion: To our knowledge, the cannulation of both IJVs for VV-ECMO in infants has not been previously reported.This approach provides stable drainage and return flows, minimizes recirculation, and avoids risks associated with femoral cannulation, including limb ischemia.The "cannulation X-sign" offers a clear radiographic marker for cannula alignment.Conclusion: Cannulation of both jugular veins for VV-ECMO is a feasible and safe alternative in infants when femoral access is not possible.Further studies are warranted to confirm its reproducibility, safety, and incorporation into VV-ECMO guidelines.