ECMO cannulation techniques in children: Heterogeneous and often complicated

Indications for ECMO are increasing, but standardized cannulation guidelines are lacking. This study aimed to describe complications and variability in management.

A single-center retrospective review of children undergoing cervical ECMO (2016-2023). Data included demographics, ECMO technique, cannula size, complications (ELSO classification), mortality and follow-up. Surgeon specialty [pediatric (PS) or cardiothoracic (CS)] and cannula fixation method (ligation vs. non-ligation) were recorded.

Twenty-seven patients underwent ECMO, mainly for congenital diaphragmatic hernia (37%). All CS used non-ligation fixation (8/27), while PS used ligation fixation (19/27). Complications occurred in 74% of patients, predominantly mechanical (52%). PS cases had more cannula malposition and surgical site bleeding. Bleeding requiring intervention occurred in two patients per group. All patients with a 6 Fr arterial cannula died from hemolysis or pump failure. At decannulation, CS repaired both vessels, whereas PS repaired the artery and ligated the vein, with heterogeneous anticoagulation strategies. Six-month follow-up ultrasound was available in 10 of 13 patients who underwent arterial repair, showing patency rates of 5/5 (100%) for repaired arteries in the non-ligation group, and 4/5 (80%) in the ligation group. Venous patency was confirmed in 2/5 (40%) of repaired veins.

Cervical ECMO cannulation carries high complication rates and heterogeneous management. All patients cannulated with a 6 Fr arterial cannula died, suggesting that an 8 Fr cannula should be used whenever technically feasible and that central ECMO should be considered when it is not.