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Most of the hospitalised patients have peripheral venous cannulae during their hospital stay and are changed at regular intervals. They are associated with complications like haematoma, extravasation, phlebitis and thrombosis. Fracture and embolisation of peripheral venous cannula (PVC) is one more possible complication which can contribute to additional morbidity. We are reporting 2 cases. In the first case, vein cannula in the external jugular vein got fractured and the fragment was retrieved with urgent surgery. In the second case, which was operated electively, the fractured fragment could not be retrieved as it migrated distally. Fracture of vein cannula is a possible complication and could be recognised with inspection of removed cannulae. Early intervention could prevent migration. Intraoperative imaging like ultrasound and fluoroscopy will help localising the retained fragment and monitor possible migration.

Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be undertaken surgically, but there are various problems with this method. Methods and Case report We removed the arterial cannula of VA-ECMO percutaneously by combining intravascular balloon dilatation and the Perclose ProGlide™ (PP) closure device in a short amount of time and the extent of bleeding was extremely small. Simultaneously, the venous cannula was removed by suturing and manual compression. We report a series of cases of percutaneous removal of VA-ECMO using intravascular balloon dilatation and PP. Conclusions By using this method, VA-ECMO removal was possible in a very short amount of time with minimal invasiveness.

OBJECTIVE To assess the ability of point-of-care ultrasound (POCUS) to identify venous cannula position in neonates on extracorporeal membrane oxygenation (ECMO) and compare with conventional imaging. STUDY DESIGN Retrospective review of 37 infants on ECMO with 51 POCUS studies between January 2017 and October 2019. Studies were reviewed for identification of venous cannula location and compared with plain radiography and echocardiography. Kappa statistic and predictive values were calculated. RESULTS Venous cannula tip position was identified in 90% of POCUS studies. Fifty percent of the cannula tips were malpositioned. Plain radiography, the most commonly used method for evaluating tip position, showed poor agreement (57%) with POCUS (kappa 0.13). There was substantial agreement (89%) between echocardiography and POCUS (kappa 0.78). CONCLUSION This study provides preliminary evidence that POCUS is more accurate than plain radiography for the evaluation of ECMO venous cannula position. Adoption of this practice may prevent potentially catastrophic ECMO complications.

Left hepatic vein draining into coronary sinus is a rare systemic vascular anomaly. Its presence is significant when it is associated with other cardiac lesions requiring surgery. We report technical challenges in a case of persistent left superior vena cava and left hepatic vein draining into coronary sinus in an adult with ostium secundum atrial septal defect, which was repaired through minimally invasive approach. The main technical challenge in this case was to achieve adequate venous drainage, which was achieved by vacuum assistance and by manipulating the position of femoral venous cannula. We approached through a right anterolateral thoracotomy and adequate venous drainage was achieved without cannulating left hepatic vein or left superior vena cava.

Severe pulmonary edema, secondary to left ventricular afterload increment, is a common problem occurring in patients receiving venoarterial extracorporeal membrane oxygenation. No consensus is currently available for its management, but several devices/procedures have been described, including an Impella device (Abiomed), balloon atrial septostomy, intraaortic balloon counterpulsation, or an additional venous cannula, as possible adjuncts. We report the feasibility and efficacy of the atrial flow regulator device (Occlutech) for left ventricular unloading in a 58-year-old patient receiving extracorporeal membrane oxygenation. However, the benefits of this device relative to simple balloon atrial septostomy need to be further investigated.

A series of historical vignettes were shared with the membership of the American Pediatric Surgical Association (APSA) in the months leading up to its 50th anniversary meeting in May, 2019. Some stories were less-known episodes from the lives of such prominent figures as William Ladd and C. Everett Koop. Others highlighted were surgeons who made significant contributions but with time have been overlooked. Examples included Herbert Coe and Oswald Wyatt, the first surgeons to devote their practices entirely to infants and children; Helen Noblett, a pediatric surgeon in Melbourne who invented a now standard device perfectly suited to sample the rectal mucosa of infants suspected of having Hirschsprung Disease; and Barbara Barlow, who fed baby rats in her Manhattan apartment to show the protective effect of breast milk on the development of experimental necrotizing enterocolitis. Great achievements were commemorated, including Morio Kasai's operation for biliary atresia, Judah Folkman's discoveries, and Lester Martin's quest for a suitable operation for teenagers with ulcerative colitis. The golden anniversary of the founding of APSA made it appropriate to recount some of the backstories behind the effort to establish a board of pediatric surgery with certification authority and the organization of APSA itself. A few anecdotes were whimsical: the story behind the first central venous cannula; how the specialty came to be called pediatric surgery; and why Robert Gross' textbook was exactly 1,000 pages long and was published with one critical chapter missing. Taken together, the vignettes of the field's surgeons, both notable and lesser-known, and their achievements show the richness of the specialty's heritage.

Left hepatic vein draining into coronary sinus is a rare systemic vascular anomaly. Its presence is significant when it is associated with other cardiac lesions requiring surgery. We report technical challenges in a case of persistent left superior vena cava and left hepatic vein draining into coronary sinus in an adult with ostium secundum atrial septal defect, which was repaired through minimally invasive approach. Main technical challenge in this case was to achieve adequate venous drainage, which was achieved by vacuum assistance and by manipulating the position of femoral venous cannula. We approached through right anterolateral thoracotomy, adequate venous drainage was achieved without cannulating left hepatic vein or left superior vena cav.

Inadequate venous drainage decreases the efficiency of extracorporeal membrane oxygenation (ECMO). Pump augmentation may even make it worse due to collapse of the venous system under negative pressures. Furthermore, recirculation is a phenomenon that occurs when oxygenated blood supplied through the infusion cannula is withdrawn directly through the drainage cannula without contributing to the oxygenation of the patient and also compromises the efficacy of the therapy. Large drainage cannulas allow for similar flow rates at lower pump speed. But percutaneous insertion of these larger cannulas could be challenging. When using a self-expandable cannula, the diameter of the cannula for the insertion can be reduced, and once inserted, its intravascular diameter maximized, resulting in a large venous cannula due to in situ expansion after mandrel removal (up to 36F). We present a retrospective series of selfexpanding venous cannula 430 or 530 mm in length in six consecutive patients undergoing venovenous (VV) ECMO. No vascular or cardiac iatrogenic injury was caused during implantation. Target flows were reached, and no clinically significant recirculation was described in any case. The use of selfexpanding drainage cannulas was safe, and efficient drainage was achieved with easy and definitive unique positioning during cannulation.

Gaining bloodless field in minimally invasive mitral valve surgery is crucial for a successful surgery. We here demonstrate a simple method to obtain bloodless field in minimally invasive mitral valve surgery with only single venous cannula through the femoral vein. A dual-stage venous cannula is inserted through the femoral vein, with its tip located deep in superior vena cava. After establishing full flow, the inferior vena cava (IVC) was snared. Returning blood from the IVC was blocked at the snare, and drained through the side holes at the midportion of the cannula. This technique collapsed the right atrium, and made the left atrium almost bloodless. Pressures of the femoral vein measured in 28 patients were 9.5 ± 4.1 mmHg before bypass, 6.8 ± 4.8 mmHg before snaring IVC, and 7.2 ± 4.8 mmHg after snaring. By blocking returning blood from the lower body, venous congestion of the lower body did not occur.

A patient with heart failure due to nonischemic cardiomyopathy presented as a transfer to our institution following peripheral (femoral) venoarterial (VA) extracorporeal membrane oxygenation (ECMO) placement. With peripheral VA ECMO cannulation, the patient continued to have unstable ventricular tachyarrhythmias. Echocardiography demonstrated left ventricular (LV) dilation and severe mitral regurgitation (MR) with clinical and chest X-ray evidence of pulmonary edema. To provide venous drainage and simultaneous decompression of the left atrium (LA) and thereby indirect LV venting, a single multistage venous cannula was placed across the inter-atrial septum (IAS) using the previously described left atrial venoarterial (LA-VA) ECMO cannulation technique. Two- and three-dimensional (3D) transesophageal echocardiography (TEE) demonstrated utility in guiding cannula placement into the appropriate position and providing real time assessment of ventricular decompression and MR severity. There was subsequent improvement in pulmonary edema. This case is thought to be the first demonstration of real time resolution of pulmonary venous flow reversal in a patient undergoing LA-VA ECMO cannulation. This demonstration offers important mechanistic insight into some of the potential benefits of such an approach.

Prolonged and neglected use of an intravenous (IV) line could be limb- and life-threatening. In many terminally sick cancer patients of rural India, pain management is a major concern. It is a very common practice by local practitioners to give IV fluids and pain medications in such patients. Where IV access is difficult, a secure venous cannula is kept in situ for long periods to administer pain medicines and fluids. This article tries to highlight the dangers a neglected IV line poses to limb and life and tries to stress on the importance of a subcutaneous route for pain medication administration in terminally ill palliative patients.

The objective of this study was to evaluate a pulsatile extracorporeal membrane oxygenation (ECMO) system in terms of hemodynamic energy generation and transmission under various pulsatile amplitudes, flow rates, and pseudopatient pressures in a simulated adult ECMO circuit. Surplus hemodynamic energy (SHE), a measure of the quality of pulsatility, was used to quantify pulsatile flow. The circuit consisted of an i-cor diagonal pump, an adult XLung oxygenator, a 21 Fr Medtronic Biomedicus femoral arterial cannula, a 23/25 Fr Sorin RAP femoral venous cannula, and 3/8 in ID tubing for both arterial and venous lines. The circuit was primed with lactated Ringer's solution and then packed red blood cells (hematocrit 37%). Trials were conducted at 36°C with flow rates of 2-5 L/min (1 L/min increments) under nonpulsatile and pulsatile mode with pulsatile amplitudes of 1000-5000 rpm (1000 rpm increments). The pseudopatient pressure was maintained at 40-100 mm Hg (20 mm Hg increments). Real-time pressure and flow data were recorded for analysis using a custom-made data acquisition system. There was no SHE generated by the pump under nonpulsatile mode. Under pulsatile mode, SHE levels increased with increasing pulsatile amplitude and pseudopatient pressure (P < 0.01) but decreased with increasing flow rate. SHE levels were significantly higher at flow rates of 2-4 L/min. In addition, the XLung oxygenator had acceptable pressure drops (36.1-104.9 mm Hg) and percentages of total hemodynamic energy loss (19.6-43.9%) during all trials. The novel pulsatile ECMO system can create nonpulsatile and pulsatile flow in an adult ECMO model. However, pulsatility gradually weakened with increasing flow rates. Pulsatile amplitude settings were found to have a great impact on pulsatility.

Objective Inadequate peripheral venous drainage during minimally invasive cardiac surgery (MICS) is a challenge and cannot always be solved with increased vacuum or increased centrifugal pump speed. The present study was designed to assess the benefit of virtually wall-less transfemoral venous cannulas during MICS. Methods Transfemoral venous cannulation with virtually wall-less cannulas (3/8″ 24F 530–630-mm ST) was performed in 10 consecutive patients (59 ± 10 years, 8 males, 2 females) undergoing MICS for mitral (6), aortic (3), and other (4) procedures (combinations possible). Before transfemoral insertion of wall-less cannulas, a guidewire was positioned in the superior vena cava under echocardiographic control. The wall-less cannula was then fed over the wire and connected to a minimal extracorporeal system. Vacuum assist was used to reach a target flow of 2.4 l/min per m2 with augmented venous drainage at less than −80 mm Hg. Results Wall-less venous cannulas measuring either 630 mm (n = 8) in length or 530 mm (n = 2) were successfully implanted in all patients. For a body size of 173 ± 11 cm and a body weight of 78 ± 26 kg, the calculated body surface area was 1.94 ± 0.32 m2. As a result, the estimated target flow was 4.66 ± 0.78 l/min, whereas the achieved flow accounted for 4.98 ± 0.69 l/min (107% of target) at a vacuum level of 21.3 ± 16.4 mm Hg. Excellent exposure and “dry” intracardiac surgical field resulted. Conclusions The performance of virtually wall-less venous cannulas designed for augmented peripheral venous drainage was tested in MICS and provided excellent flows at minimal vacuum levels, confirming an increased performance over traditional thin wall cannulas. Superior results can be expected for routine use.

We present a case report of a patient with a pulmonary embolus placed on venoarterial extracorporeal membrane oxygenation who developed venous cannula migration through an undiagnosed patent foramen ovale causing an ischemic stroke due to a thrombus and requiring thrombectomy and device closure of the atrial defect.

We report two cases of inferior vena cava (IVC) thrombosis after the retrieval of veno-arterial extracorporeal membrane oxygenation cannulas. In both patients, the venous cannula tips were placed in the upper half of the right atrium, enabling adequate blood drainage. During support, uneventful periods of IVC collapse were detected. After decannulation, thrombotic formations resembling a mold of the venous cannula were detected in both patients. Whether the IVC collapse caused IVC thrombosis during VA-ECMO support remains to be determined in further trials.

Introduction: Recent advances to make cardiopulmonary bypass more physiological include the use of kinetic-assisted venous drainage but without a venous reservoir. Despite manipulation of intravascular volume and patient positioning, arterial flow is frequently reduced. Negative venous line pressures can be generated, which may elicit gaseous microemboli. We investigated the influence of venous cannula design on venous return and negative venous line pressures. Methods: In a single-centre, single-surgeon, prospective, randomized, double-blind trial, 48 patients undergoing isolated coronary artery, aortic valve or combined coronary artery and aortic valve surgery, with a minimally invasive circuit, were randomized to a conventional two-stage (2S) or three-stage venous cannula (3S), or to a three-stage venous cannula with additional ‘fenestrated’ ridges (F3S). Blood flow, venous line pressures and gaseous microemboli number and size were measured. Results: The pump flow achieved was the same between groups, but in each case fell below the target range of 2.2–2.4 L min–1 m–2. The three-stage cannula recorded significantly lower negative pressure than the other cannulae. The total count and volume of gaseous emboli detected with the F3S cannulae was very high in some cases, with wide heterogeneity. Discussion: The low negative pressures recorded with three-stage cannula, despite having a larger drainage orifice area, suggest that negative pressure may be more influenced by lumen diameter and vena cava collapse rather than drainage hole size. The additional fenestrations resulted in flow characteristics and negative pressures similar to the larger two-stage cannula but are associated with generation of gaseous microemboli.

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Background and Aims: Continuous venovenous hemofiltration or hemodiafiltration is used frequently in pediatric patients, but experience of continuous renal replacement therapy (CRRT) application on extracorporeal membrane oxygenation (ECMO) circuit is still limited. Among several methods used for applying CRRT on ECMO patients, we aim to share our experience on inclusion of a CRRT device in the ECMO circuit which we believe is easier and safer to apply. Materials and Methods: The data were collected on demographics, outcomes, and details of the treatment of ECMO patients who had CRRT. During the study period of 3 years, venous cannula of ECMO circuit before pump was used for CRRT access for both the filter inlet and outlet of CRRT machine to minimize the thromboembolic complications. The common indication for CRRT was fluid overload. Results: CRRT was used in 3.68% of a total number of patients admitted and 43% of patients on ECMO. The patients have undergone renal replacement therapy for periods of time ranging between 24 h and 25 days (260 h mean). The survival rate of this group of patients with multiorgan failure was 33%. Renal recovery occurred in all of the survivors. Complications such as electrolyte imbalance, hypothermia, and bradykinin syndrome were easily managed. Conclusions: Adding a CRRT device on ECMO circuit is a safe and effective technique. The major advantages of this technique are easy to access, applying CRRT without extra anticoagulation process, preventing potential hemodynamic disturbances, and increased clearance of solutes and fluid overload using larger hemofilter.

No Abstract

Septic pulmonary emboli can occur as a complication of many diseases, most common being right sided infective endocarditis. Septic emboli through a peripheral venous cannula are rarely reported in literature though central venous catheter is commonly implicated. We describe a case of widespread cellulitis and septic pulmonary emboli as a complication of peripheral venous cannulation.

Purpose Peripherally inserted central catheters (PICC) are used extensively in neonates. However, insertion of these thinnest catheters is a very delicate procedure. We developed an easy and safe insertion technique for 2-French (F) PICCs with a new fine-tipped introducer cannula created without modifying commercial products by advancing a 24-gauge peripheral venous cannula through a half-peeled (20-gauge) introducer cannula. We evaluated neonates treated with our new PICC insertion technique. Methods Information was collected retrospectively on all 32 2-F PICCs inserted during the 4-year period from November 2010 to November 2014. We monitored neonates, recording the success rate of placement, number of insertion attempts, reasons for removal, and complications. Results In total, 32 2-F PICCs were placed in 31 patients (19 (61%) males and 12 (39%) females; median age 7 (range: 1–36) days, median weight 2200 (range: 800–4100) g) using the new technique. The vein accessed most commonly was the long saphenous vein (87%). The duration of catheterization was 10.3±4.2days. Almost all PICCs were inserted successfully (32/33, success rate 97%) and in the first venipuncture (28/32, 88%). Of the PICCs, 81% were removed after completion of therapy or upon death. Two minor bleeding complications were noted at the insertion site. Conclusions This novel technique is an easy and safe way of inserting a 2-F PICC in neonates. It can be used by anyone in a neonatal unit who can insert a 24-gauge peripheral venous access.

Vacuum-assisted venous drainage (VAVD) is a well-known technique widely used in both adult and pediatric cardiac surgery. During the last 10 years VAVD has been mainly used to reduce hemodilution during cardiopulmonary bypass (CPB) as it allows for a “lower prime” circuit, and smaller venous cannula during minimally invasive cardiac surgery (MICS) procedures without compromising patient blood flow. Combined with VAVD, the use of shorter circuits, smaller cannula and eventually lower priming volume, is closely associated to the ability to reduce homologous blood transfusion.

A chimney femoral artery graft for peripheral extracorporeal membrane oxygenation can potentially cause hyperperfusion and subsequent venous congestion in the ipsilateral leg, especially in the context of septic shock and higher flow requirement. This report describes a novel technique to use an additional leg venous cannula to avoid leg congestion as well as to achieve higher total flow.

Venous cannula orifice obstruction is an underestimated problem during augmented cardiopulmonary bypass (CPB), which can potentially be reduced with redesigned, virtually wall-less cannula designs versus traditional percutaneous control venous cannulas. A bench model, allowing for simulation of the vena cava with various affluent orifices, venous collapse and a worst case scenario with regard to cannula position, was developed. Flow (Q) was measured sequentially for right atrial + hepatic + renal + iliac drainage scenarios, using a centrifugal pump and an experimental bench set-up (afterload 60 mmHg). At 1500, 2000 and 2500 RPM and atrial position, the Q values were 3.4, 6.03 and 8.01 versus 0.77*, 0.43* and 0.58* l/min: p® cannula, respectively. The corresponding pressure values were -15.18, -31.62 and -74.53 versus -46.0*, -119.94* and -228.13* mmHg. At the hepatic position, the Q values were 3.34, 6.67 and 9.26 versus 2.3*, 0.42* and 0.18* l/min; and the pressure values were -10.32, -20.25 and -42.83 versus -23.35*, -119.09* and -239.38* mmHg. At the renal position, the Q values were 3.43, 6.56 and 8.64 versus 2.48*, 0.41* and 0.22* l/min and the pressure values were -9.64, -20.98 and -63.41 versus -20.87 -127.68* and -239* mmHg, respectively. At the iliac position, the Q values were 3.43, 6.01 and 9.25 versus 1.62*, 0.55* and 0.58* l/min; the pressure values were -9.36, -33.57 and -44.18 versus -30.6*, -120.27* and -228* mmHg, respectivly. Our experimental evaluation demonstrates that the redesigned, virtually wall-less cannulas, allowing for direct venous drainage at practically all intra-venous orifices, outperform the commercially available control cannula, with superior flow at reduced suction levels for all scenarios tested.

A new caval tree system was designed for realistic in vitro simulation. The objective of our study was to assess cannula performance for virtually wall-less versus standard percutaneous thin-walled venous cannulas in a setting of venous collapse in case of negative pressure.For a collapsible caval model, a very flexible plastic material was selected, and a model with nine afferent veins was designed according to the anatomy of the vena cava. A flow bench was built including a lower reservoir holding the caval tree, built by taking into account the main afferent vessels and their flow provided by a reservoir 6 cm above. A cannula was inserted in this caval tree and connected to a centrifugal pump that, in turn, was connected to a reservoir positioned 83 cm above the second lower reservoir (after-load = 60 mmHg). Using the same pre-load, the simulated venous drainage for cardiopulmonary bypass was realized using a 24 F wall-less cannula (Smartcanula) and 25 F percutaneous cannula (Biomedicus), and stepwise increased augmentation (1500 RPM, 2000 and 2500 RPM) of venous drainage.For the thin wall and the wall-less cannulas, 36 pairs of flow and pressure measurements were realized for three different RPM values. The mean Q-values at 1500, 2000 and 2500 RPM were: 3.98 ± 0.01, 6.27 ± 0.02 and 9.81 ± 0.02 l/min for the wall-less cannula (P0.0001), versus 2.74 ± 0.02, 3.06 ± 0.05, 6.78 ± 0.02 l/min for the thin-wall cannula (P0.0001). The corresponding inlet pressure values were: -8.88 ± 0.01, -23.69 ± 0.81 and -70.22 ± 0.18 mmHg for the wall-less cannula (P0.0001), versus -36.69 ± 1.88, -80.85 ± 1.71 and -101.83 ± 0.45 mmHg for the thin-wall cannula (P0.0001). The thin-wall cannula showed mean Q-values 37% less and mean P values 26% more when compared with the wall-less cannula (P0.0001).Our in vitro water test was able to mimic a negative pressure situation, where the wall-less cannula design performs better compared with the traditional thin-wall cannula.

The management of massive venothromboembolism (VTE) with “clot-in-transit” classically involves surgical embolectomy; however, selected patients may be at prohibitive risk for surgical treatment. We describe a complex case involving a massive right atrial thrombus extending from a venous cannula