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Figure. Axillary artery and subclavian vein cannulation for extracorporeal membrane oxygenation.

5.0 L/min ﬂow was considered adequate with reversal of endorgan dysfunction and no evidence of metabolic acidosis. A
more durable LVAD (HeartWare HVAD, Framingham, MA)
was implanted with aortic valve replacement and concomitant ECMO decannulation. There was no evidence of wound
complications, infections related to the exposed graft, or limb
complications, and recovery was unremarkable. On day 14, the
patient received an automatic implantable cardioverter deﬁbrillator and was discharged home the next day without complications. He is still awaiting a donor heart.
DISCUSSION
ECMO has become an essential tool in the care of patients
with severe cardiac and pulmonary dysfunction who are refractory to conventional management. The technique has become
more reliable due to improvements in equipment and increased
experience (3). The indications have been extended to more
prolonged use in the intensive care unit, such as for bridge to
transplant for both cardiac and lung transplantation and for
support in cardiopulmonary replacement therapy in unstable
patients (4, 5). ECMO support can be deployed with multiple
techniques, including peripheral or central cannulation. Both
methods of cannulation carry risks of bleeding, while peripheral
cannulation carries an added risk of limb ischemia (2).
The most common route for peripheral cannulation in
venoarterial ECMO involves the common femoral artery and
vein (3). However, in addition to the risk of injury to the artery,
blood ﬂow to the heart and brain is mostly retrograde with
direct cannulation of the femoral artery. Although we have
adopted the former technique in our center, we shifted our
practice toward subclavian venoarterial cannulation in order to

April 2017

reduce complications and to increase ﬂow to the upper body.
Potential risks of this new subclavian technique include cannula
dislodgement during ambulation or physical therapy, subclavian vein thrombosis, arterial "overcirculation"/edema to the
upper extremity, requirement of imaging techniques for cannula
placement, and arterial or venous injury from cannulation.
Patients on venoarterial ECMO support have traditionally
been considered too unstable for active physical therapy, are
frequently heavily sedated, and occasionally are on neuromuscular blocking agents. However, the ability to ambulate while
on venoarterial ECMO has been facilitated by advances in extracorporeal technology and cannulation techniques (6). Neuromuscular weakness and impairment in physical functioning
are common sequelae of immobilization during critical illness.
Active participation in physical and occupational therapy is
not only considered safe and feasible, but is also the preferred
approach to minimize debilitation in critically ill patients. Early
rehabilitation is associated with improved rates of return to
independent functioning, decreased rates of delirium, shorter
durations of mechanical ventilation, and shorter length of stay
in the intensive care unit and the hospital (7). Thus, subclavian
venoarterial cannulation for ECMO may increase patient mobility and lead to quick recovery. Moreover, this methodology
may enable longer durations of venoarterial ECMO support,
potentially allowing patients to achieve multisystem recovery
and a lower risk proﬁle for undergoing cardiac transplantation
or LVAD implantation.
1.

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Mason D, Gonzalez-Stawinski GV. Outcomes of axillary artery side graft
cannulation for extracorporeal membrane oxygenation. J Thorac Cardiovasc
Surg 2013;145(4):1088-1092.
Squiers JJ, Lima B, DiMaio JM. Contemporary extracorporeal membrane
oxygenation therapy in adults: fundamental principles and systematic
review of the evidence. J Thorac Cardiovasc Surg 2016;152(1):20-32.
Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL, Leger P, Pavie A,
Chastre J. Outcomes and long-term quality-of-life of patients supported
by extracorporeal membrane oxygenation for refractory cardiogenic shock.
Crit Care Med 2008;36(5):1404-1411.
Marasco SF, Esmore DS, Negri J, Rowland M, Newcomb A, Rosenfeldt FL,
Bailey M, Richardson M. Early institution of mechanical support improves
outcomes in primary cardiac allograft failure. J Heart Lung Transplant
2005;24(12):2037-2042.
Javidfar J, Brodie D, Costa J, Miller J, Jurrado J, LaVelle M, Newmark A,
Takayama H, Sonett JR, Bacchetta M. Subclavian artery cannulation for venoarterial extracorporeal membrane oxygenation. ASAIO J
2012;58(5):494-498.
Abrams D, Javidfar J, Farrand E, Mongero LB, Agerstrand CL, Ryan P,
Zemmel D, Galuskin K, Morrone TM, Boerem P, Bacchetta M, Brodie D.
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Ambulatory ECMO with subclavian venoarterial cannulation to increase mobility and recovery

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https://www.elso.org/Registry/Statistics/InternationalSummary.aspx https://www.elso.org/Registry/Statistics/InternationalSummary.aspx

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