Intensive Care Med

https://doi.org/10.1007/s00134-020-06008-3

IMAGING IN INTENSIVE CARE MEDICINE

A strange position of a venous drainage

ECMO cannula
Frederic Caruso1, Simone Giglioli1, Ilias Bennouna2 and Daniel De Backer1*

© 2020 Springer-Verlag GmbH Germany, part of Springer Nature

Dual cannulation was performed under ultrasound
guidance for venovenous ECMO in this patient with
severe ARDS. A multiperforated 25F drainage cannula
(MEDTRONIC Biomedicus Multistage Venous Femoral
25Fr × 60 cm) was inserted via the left femoral vein, and
its tip was positioned at the entrance of the right atrium
as confirmed by transesophageal echocardiography. The
return cannula was inserted through right jugular access.
After 10 days of uneventful ECMO run, an abdominal CT
scanner was performed to identify the source of recur-
rent sepsis. Surprisingly, the drainage cannula was posi-
tioned on the left side of the aorta (Fig. 1a). In this patient
presenting a dual inferior vena cava (IVC), the drainage
cannula entered the left iliac vein, continuing into the left
IVC, the left renal vein and then the common part of the
IVC just before entering the thorax (Fig. 1b, c).
The incidence of dual IVC is estimated at 0.2–0.6%.
Duplicated infrarenal IVC segments may result in serious
issues during attempts of IVC cannulation from femoral
vein access, especially with persistent azygos circulation
(Fig.  1d). Ultrasound guidance is of particular help in
these conditions often unknown at time of ECMO inser-
tion, allowing visualization of the guidewire in proper
position in the inferior vena cava at its entrance into the
right atrium.

*Correspondence: ddebacke@ulb.ac.be
1
Department of Intensive Care, CHIREC Hospitals, Université Libre de
Bruxelles, Boulevard du Triomphe 201, 1160 Brussels, Belgium
Full author information is available at the end of the article
 Fig. 1  a Transverse view of the two inferior vena cava with the ECMO drainage cannula in the left IVC. The drainage cannula was positioned in a
vessel at the left side of the aorta. b ECMO cannula in left IVC terminating in the main IVC. In this patient, the dual IVC was characterized by the
persistence of a left-sided IVC draining into the left renal vein which merged with some angulation the right-sided IVC just before the entrance in
the thorax and right atrium. c Schematic representation of the main dual IVC variants. c Represents the actual variant that this patient presented.
This variant carries a risk of perforation of renal vein at its junction with left IVC (and insertion of the drainage cannula into the retroperitoneal space)
during left femoral access. d Represents the other main variant of a dual vena cava, with prolongation into an azygos vein, ultimately draining into
the superior vena cava through brachiocephalic veins. In this less frequent variant, the suprarenal part of IVC is absent, and blood is drained though
the azygos vein (usually left). The azygos vein is of smaller size, and this variant is at high risk of perforation at several places (junction of IVC with
renal veins as well as azygos vein at any place) during either right or left femoral access

Author details
1
Publisher’s Note
 Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Springer Nature remains neutral with regard to jurisdictional claims in pub-
Boulevard du Triomphe 201, 1160 Brussels, Belgium. 2 Department of Radiol- lished maps and institutional affiliations.
ogy, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.
Received: 29 January 2020 Accepted: 9 March 2020
Compliance with ethical standards

Conflicts of interest
The authors have no conflict of interest to declare.