Percutaneous Closure of Peripheral ECMO Cannulation Sites
Patients who undergo rapid cannulation for ECMO cardiopulmonary bypass resuscitation (eCPR) have large cannulas placed in the femoral vessels. When ECMO is no longer needed these cannulas have typically been removed. The arterial and venous cannulas, which are very large, are removed using a surgical cut-down on the femoral vessels and primary repair of the artery and vein. However, surgical closure is time consuming and is associated with periprocedure related complications including bleeding, wound infection, and hemodynamic instability.
This video presents the use of a percutaneous closure device to perform suture-mediated closure at these wound sites. At the authors’ institution, the Abbott Perclose device is used for percutaneous closures. Typically, this device is deployed prior to the creation of a large arteriotomy in settings such as TAVR or nonemergent ECMO cannulation. However, this technique is novel in that the devices are used after a large arteriotomy has been made by the emergent cannulation. The use of this technique is associated with reduced operative time and postoperative complications compared to open groin cut down.
This video shows a case using this technique technique as well as a retrospective series of patients who have undergone percutaneous versus traditional cut down closure for ECMO decannulation.
The Surgery
After the patient was brought to the operating room, the groin was prepared and draped in normal fashion. The arterial and venous cannulas were clamped and cut free from circuit tubing. The ECMO circuit was recirculated for fifteen minutes while the patient was tested off ECMO. The patient tolerated the recirculation period based on hemodynamics and blood gases, so the team proceeded with decannulation. The procedure was performed with the patient maintained on a heparin infusion.
First, wire access was gained by an 18 G needle in the arterial cannula. Access was confirmed by transesophageal echo.
The cannula was then removed in a controlled fashion over the wire and pressure was held over the cannulation site for hemostasis. Importantly, the needle was maintained inside the cannula so that the wire passed through the cannula smoothly.
The device was then deployed over the wire with slight medial rotation. A second device was deployed with the device in slight lateral rotation to evenly space out sutures. Next, wire access was re-established and the knot pusher was used to firmly secure the Prolene sutures in place. Distal perfusion was confirmed by back bleeding from the distal perfusion cannula.
Next, the venous catheter was removed with a deep purse string overlying the cannulation site and gentle venous compression for ten minutes. Pressure was also held over the 5 French distal perfusion catheter site after its removal.
Occasionally, a third Perclose is deployed if hemostasis is not achieved or one Perclose application fails to pass through the arterial wall, or the sutures are completely pulled out during plunger pull back.
Conclusion
Post cannulation closure (Post-close) using percutaneous suture-mediated closure can successfully reduce operative time and appears associated with reduced wound infection compared to traditional groin closure.
Reference(s)
Hwang J-w, Yang JH, Sung K, et al. Percutaneous removal using Perclose ProGlide closure devices versus surgical removal for weaning after percutaneous cannulation for venoarterial extracorporeal membrane oxygenation. Journal of vascular surgery. 2016;63(4):998-1003. e1.
Majunke N, Mangner N, Linke A, et al. Comparison of percutaneous closure versus surgical femoral cutdown for decannulation of large-sized arterial and venous access sites in adults after successful weaning of veno-arterial extracorporeal membrane oxygenation. J Invasive Cardiol. 2016;28(10):415-419.
Lüsebrink E, Stremmel C, Stark K, et al. Percutaneous Decannulation Instead of Surgical Removal for Weaning After Venoarterial Extracorporeal Membrane Oxygenation-A Crossed Perclose ProGlide Closure Device Technique Using a Hemostasis Valve Y Connector. Crit Care Explor. Jun 2019;1(6):e0018. doi:10.1097/cce.0000000000000018
Danial P, Hajage D, Nguyen LS, et al. Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study. Intensive care medicine. 2018;44(12):2153-2161.
Shah A, Ghoreishi M, Taylor BS, et al. Complete percutaneous decannulation from femoral venoarterial extracorporeal membrane oxygenation. JTCVS Techniques. 2021/04/01/ 2021;6:75-81. doi:https://doi.org/10.1016/j.xjtc.2020.11.005
Choi CH, Hall JK, Malaver D, Applegate RJ, Zhao DXM. A novel technique for postclosure of large‐bore sheaths using two Perclose devices. Catheterization and cardiovascular interventions. 2021;97(5):905-909. doi:10.1002/ccd.29351
