Underrated but valuable: utility of left subclavian venous access for dual lumen cannulation

10147 

Abstract Submission 

John Eisenga (1), Kara Monday (1), Britton Blough (1), Michael Foreman (1), Kaitlyn Lingle (1), Dan Meyer (2), Gary Schwartz (1)

(1) Baylor University Medical Center, Dallas, TX, (2) Baylor Scott & White Health, Dallas, TX

John Eisenga    -  Contact Me
Baylor University Medical Center

Kara Monday    -  Contact Me
Baylor University Medical Center

Britton Blough    -  Contact Me
Baylor University Medical Center

Michael Foreman    -  Contact Me
Baylor University Medical Center

Kaitlyn Lingle    -  Contact Me
Baylor University Medical Center

*Dan Meyer    -  Contact Me
Baylor Scott & White Health

Gary Schwartz    -  Contact Me
Baylor University Medical Center

John Eisenga    -  Contact Me
Baylor University Medical Center

Objectives: Dual lumen cannulation for extracorporeal support is increasingly utilized, with proposed benefits of increased mobility, decreased insertion site infections, ease of nursing care, and patient comfort. The right internal jugular vein is the predominant approach for such cannulation, however the left subclavian vein has several potential advantages including cannula stability, ease of nursing care, and decreased bloodstream infections. Experience with this location – including technical aspects, procedural and long-term complications, and outcomes – are under-reported.

Methods: A retrospective review was performed for a single high volume ECMO center. All patients who were cannulated using the left subclavian venous approach were included. Primary end points were cannulation-related complications and survival. Secondary end points included patient demographics, indication(s), type of cannula, time on ECMO, and anticoagulation regimen.

Results: From 2012 to 2024 a total of 1385 patients were supported on ECMO. Of these, 24 were cannulated via the left subclavian vein: 22 were venovenous utilizing the Crescent™ (Medtronic, Minneapolis, MN) cannula for respiratory failure with preserved right ventricular function and 2 were venopulmonary for right ventricular failure using the ProtekDuo™ (LivaNova, London, UK) and Quantum (Spectrum Medical, Gloucester, UK) cannulas. Five were primary cannulations and 19 were revisions from another configuration due to blood stream infections (5); transition from a venoarterial configuration (2), or to promote reconditioning during long runs (12). There were no cannulation associated complications. There were no cannulation site infections or significant bleeding, although 2 patients developed left upper extremity deep venous thrombosis. 10/24 (41%) patients survived to discharge neurologically intact. Demographics are listed in Table 1, with several patients having multiple indications for extracorporeal support and profoundly long ECMO runs.

Discussion: The left subclavian is an underutilized access point for dual lumen venovenous and venopulmonary extracorporeal support. It is particularly useful for revision from femoral/jugular configurations when indicated. Deep venous thrombosis may be more frequent than other sites, necessitating therapeutic anticoagulation if not already employed. Technical considerations include more inferolateral cutaneous access than with small bore subclavian access, a stiffer guidewire, and mandatory fluoroscopic guidance.

ECMO/Mechanical Support