Baylor University Medical Center Proceedings April 2017 - 224

Ambulatory extracorporeal membrane oxygenation with
subclavian venoarterial cannulation to increase mobility
and recovery in a patient awaiting cardiac transplantation
Samuel Jacob, MD, Juan C. MacHannaford, MD, Themistokles Chamogeorgakis, MD, Gonzalo V. Gonzalez-Stawinski, MD,
Joost Felius, PhD, Aldo E. Rafael, MD, Rajasekhar S. Malyala, MD, and Brian Lima, MD

xtracorporeal membrane oxygenation (ECMO) is increasingly utilized in patients with refractory cardiopulmonary disease (1). For patients with refractory heart
failure, venoarterial ECMO can provide temporary
hemodynamic stabilization as a bridge to more durable therapies. In most instances, venoarterial ECMO is achieved via
femoral cannulation, rendering patients supine for the entire
duration of support and susceptible to limb ischemia associated
with femoral arterial cannulation. We previously reported good
outcomes with subclavian arterial cannulation to avoid these
complications (2). We recently modiﬁed this strategy to concomitant arterial and venous subclavian cannulation to enable
ambulation and to promote potentially faster recovery. Here
we report a recent patient supported with ambulatory subclavian venoarterial ECMO who was successfully bridged to left
ventricular assist device (LVAD) implantation and is currently
awaiting cardiac transplantation.

tory shocks. Amiodarone infusion and inotropic support with
milrinone and dobutamine were started. An intraaortic balloon
pump was placed, and he was tentatively listed status 1A for
cardiac transplantation. However, despite the level of support
and continued escalation of inotropic agents, he failed to achieve
adequate hemodynamics or normalizing indices of end-organ
perfusion.
Consequently, we proceeded with urgent venoarterial
ECMO support in an eﬀort to stabilize him before deciding on
advanced therapy. To provide the patient with more ﬂexibility
and mobility, we opted for subclavian venoarterial cannulation. The left side was chosen because of his right-handedness.
The subclavian artery was exposed through a left infraclavicular
incision along the level of the deltopectoral groove and was
mobilized circumferentially. The brachial plexus was preserved.
After heparin was administered, a side-biting Satinsky vascular
clamp was applied to the subclavian artery, a 1-cm arteriotomy
was created, and an 8-mm Gelsoft Plus graft (Sulzer Vascutek,
Austin, TX) was sewn onto the artery in end-to-side fashion.
The graft was tunneled subcutaneously down to the nipple level.
A 21F arterial cannula was placed through the externalized graft
and directed to within 1 cm of the anastomosis. The graft was
secured to the cannula by tying umbilical tapes and to the skin
by multiple silk sutures. The venous cannulation was achieved
percutaneously under ﬂuoroscopic guidance using the Seldinger
technique. A 22F QuickDraw venous cannula (Edwards Lifesciences, Irvine, CA) was secured to the skin with multiple
sutures after being tunneled subcutaneously, as with the arterial
cannula (Figure).
The patient was extubated on day 1 after surgery, sat on a
chair on day 2, and rode a stationary bicycle on day 4. His listing status remained the same, but no suitable donor was found
for 9 days, during which he remained on ECMO. The 3.5 to

CASE REPORT
A 59-year-old man with hypertension and sleep apnea was
diagnosed with heart failure secondary to nonischemic cardiomyopathy. A recent echocardiogram revealed a left ventricular
ejection fraction of 7% and moderate aortic valvular insuﬃciency. His heart failure symptoms progressed, and he presented
to our institution with repeated episodes of ventricular ﬁbrillation, requiring cardiopulmonary resuscitation and deﬁbrilla-

From the Department of Cardiac and Thoracic Surgery (Jacob, MacHannaford,
Chamogeorgakis, Gonzalez-Stawinski, Rafael, Malyala, Lima) and the Annette C.
and Harold C. Simmons Transplant Institute (MacHannaford, Chamogeorgakis,
Gonzalez-Stawinski, Felius, Rafael, Malyala, Lima), Baylor University Medical
Center at Dallas, Texas.
Corresponding author: Brian Lima, MD, Department of Cardiac and Thoracic
Surgery, Baylor University Medical Center at Dallas, 3900 Junius St., Suite 415,
Dallas, TX 75246 (e-mail: brian.lima@bswhealth.org).

Venoarterial extracorporeal membrane oxygenation (ECMO) can provide
temporary cardiopulmonary support for patients in hemodynamic extremis or refractory heart failure until more durable therapies-such as
cardiac transplantation or a left ventricular assist device-can be safely
implemented. Conventional ECMO cannulation strategies commonly employ the femoral artery and vein, constraining the patients to the supine
position for the duration of ECMO support. We have recently adopted a
modified cannulation approach to promote patient mobility, rehabilitation,
and faster recovery and to mitigate complications associated with femoral
arterial cannulation, such as limb ischemia and compartment syndrome.
This technique involves cannulation of the subclavian artery and vein.
The current case report details our recent experience with this approach
in a critically ill patient awaiting cardiac transplantation.

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Proc (Bayl Univ Med Cent) 2017;30(2):224-225

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