Bicaval dual lumen cannula placement using transthoracic echocardiography in COVID-19 scenario: pearls and pitfalls

Area of Science:

• Cardiology
• Critical Care Medicine
• Medical Imaging

Background:

• COVID-19 is associated with an increased risk of venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE).
• Severe respiratory failure in COVID-19 may necessitate extracorporeal membrane oxygenation (ECMO) for કાર્ડiac and respiratory support.
• Inferior vena cava (IVC) filters are used to prevent PE in patients with DVT, but can complicate central venous access.

Observation:

• A COVID-19 patient developed extensive DVT extending into the IVC, requiring an IVC filter.
• Despite mechanical ventilation, the patient's respiratory failure worsened, necessitating rescue therapy with venovenous ECMO (VV-ECMO).
• The presence of the IVC filter precluded standard femoro-jugular VV-ECMO, necessitating a single-site venous cannulation approach.

Findings:

• A bicaval dual-lumen (Avalon) cannula was selected for VV-ECMO via single-site venous access.
• Conventional guidance methods (fluoroscopy, transesophageal echocardiography) were not feasible due to COVID-19 patient management protocols.
• Transthoracic echocardiography (TTE) was successfully employed to guide Avalon cannula placement.
• The 'bending' sign on TTE was identified as a crucial indicator to detect and prevent potential guidewire malposition and right ventricular rupture.

Implications:

• Transthoracic echocardiography represents a feasible and potentially life-saving guidance technique for Avalon cannula placement in complex COVID-19 cases.
• Careful adherence to a detailed protocol during TTE-guided cannulation is essential to mitigate risks of cannula malposition.
• This case highlights the adaptability of ECMO techniques in managing critical COVID-19 complications and venous thromboembolism.