68014 PRF28210.1177/0267659112468014PerfusionKohler et al.
Review
ECMO cannula review
K Kohler,1 K Valchanov,2 G Nias2 and A Vuylsteke2
Abstract
This paper reviews the basic fluid dynamics underlying extracorporeal membrane oxygenation (ECMO) cannula design.
General cannula features and their effect on flow are discussed and the specific requirements of different ECMO circuits
are explained. The current commercially available cannula options for veno-arterial and veno-venous circuits are
reviewed and the main characteristics presented.
Keywords
ECMO; extracorporeal; cannula; flow; fluid dynamics
Introduction
Extracorporeal membrane oxygenation (ECMO) is a
treatment for patients unable to sustain life with phar-
macological and ventilator support. The success of
ECMO is greatly dependent on adequate blood flow
through the extracorporeal circuit. The cannula provides
the interface between circuit and patient. Cannula choice
will be informed by an appropriate understanding of the
different features of cannulae and how they affect flow.
Cannula theory
Simplified fluid dynamics
Bernoulli equation. The simplified Poiseuille equation
DPr 4
F∝ (where F is the flow, μ is the viscosity, r is the
µL
radius, L is the length of the cannula, and ΔP is the pressure
across the cannula) states that the maximum flow is
inversely proportional to the cannula length and directly pro-
portional to the fourth power of the radius for a circular cross-
section can nula. This equation is often used for approximate
calculations of flow and can be expanded to include frictional
pressure terms and the influence of elevation.1
Navier-Stokes equation. The Poiseuille equation is a com-
monly used simplification of the more general Navier-
Stokes equation which describes the flow of an
incompressible fluid (such as blood) and is based on the
principles of conservation of mass and momentum
ρ D u =∇p+ρg +µ∇2 u , where u is the velocity, p is the
→ →
Dt
pressure, ρ is the density, μ is the viscosity, and g is the
body force (e.g. gravity).2
Perfusion
28(2) 114­–124
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co.uk/journalsPermissions.nav
DOI: 10.1177/0267659112468014
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This equation can be solved to describe the pressures
and flow velocities if the shape of the volume and the
conditions at the edge of the cannula are specified. A
description of the pressure and flow velocities can then
be obtained.
The Navier-Stokes equation is a general description of
flow. It requires making simplifying assumptions about
flow and geometry to solve most real-life situations ana-
lytically. The most common simplification is to assume a
steady state flow, i.e. no changes in flow with respect to
time. This is a reasonable assumption in an ECMO cir-
cuit if the flow in the cannula is non-pulsatile and stable.
Even when solving these equations without simplifica-
tions, further specifications are necessary, such as the
boundary conditions and the shape of the volume in
question.
Laminar and turbulent flow, viscosity and Reynolds
number. Viscosity describes the internal resistance of a
fluid to external stresses, such as shear forces. The
1Department of Anaesthesia, West Suffolk Hospital, Bury St Edmunds,
UK
2Department of Anaesthesia and Intensive Care, Papworth Hospital,
Papworth Everard, Cambridgeshire, UK
Corresponding author:
Katharina Kohler
Hardwick Lane
Bury St Edmunds
IP33 2QZ
UK
Email: kako79@gmail.com
Kohler et al. 115

Reynolds number is a quantitative assessment of viscosity

used to describe fluid properties. Viscous flows can be
laminar or turbulent. Laminar flow has no flow perpen-
dicular to the overall flow direction and the streamlines
(lines along which dye would travel if injected into the
flow) are parallel. At high fluid velocities, these parallel
streamlines break down because some of the flow energy
is converted into a rotational movement. Part of the
motion becomes perpendicular to the overall direction
and results in turbulence. Part of the kinetic energy is lost
into the rotation of the fluid and turbulent flow has a
lower velocity for the same pressure applied. The rota-
tional element of the flow means that there will be shear
forces acting on the fluid particles.
At high Reynolds numbers (low viscosity), the effect of
the viscous forces on flow can be neglected except close to
the boundaries where the flow velocity has to be nearly
stationary. This means that the overall flow can be divided
into two parts: (1) a central inviscous laminar flow and (2)
a turbulent boundary layer where the viscous forces are
dominant. This description is incorrect when the central
flow velocity increases past a threshold where it becomes
turbulent. The change of laminar flow to turbulent flow
happens at a threshold Reynolds number. The value
depends on the surface conditions and the shape of the
flow volume. This breakdown also happens at lower veloc-
ities if the flow has existing fluctuations or is unsteady.
In addition to the turbulence associated with bound-
ary layers, other properties of cannulae, such as bends,
junctions or divergences, can cause increased turbu-
lence in the flow by introducing motion perpendicular
to the streamlines. An example of this is the effect called
boundary layer separation by which the boundary layer
detaches from the cannula wall, resulting in stagnation
points and small vortices. Drainage or inflow holes
result in turbulences and vortices in the flow near the
holes (Figure 1).

Container. Concepts of fluid dynamics and turbulence

are important as they provide the basis of limitations to
maximal flow. Most real-life volumes, such as a cannula,
are more complex than a simple cylinder: changes in
diameter or shape, confluence of flow or drainage
through side holes, steps due to connection tubing all
contribute to variations in flow and create conditions
conducive to turbulence.
The shear forces in turbulent flow can damage red
blood cells, resulting in haemolysis. The shear forces
are usually attributed to turbulent flow, but can also be
due to small pressure fluctuations in the fluid – e.g.
due to pump instability in the ECMO setting.3 Even if
the red blood cells are not destroyed, damage inflicted
on the cells can leave them susceptible to destruction
by other causes.4 Stagnation points in the flow can
result in conditions conducive to clotting or the collec-
tion of emboli.
Figure 1. a) Laminar flow; b) Boundary layers; c) Boundary
layer separation in expanding flow; d) Converging flow; e) Flow
through side holes.
Computational fluid dynamics. The flow through compli-
cated shapes cannot be described analytically, but can
only be calculated using computer simulations. Compu-
tational fluids dynamics (CFD) is the technique by which
the equations and boundary conditions are solved with
numerical methods to give accurate estimates of the flow
characteristics, such as pressure and velocity with time
and location. These methods are particularly useful
when trying to evaluate flow in a setting with bends,
drainage holes and variable cross-sections. Computa-
tional solutions can be difficult as high spatial and
116
Figure 2. a) Introducer; b) Cannula with side holes, tapered end and side port; c) Assembled cannula for insertion; d) Cannula with
Luer lock reperfusion arm.
temporal resolution is needed for accurate results. A
commonly used approach is to use time-averaged equa-
tions (Reynolds-averaged Navier-Stokes equations –
RANS) where the velocity is split into a mean and a
variable component to allow for efficient numerical
solutions.5
CFD simulations of cannula flow are complex and
often only possible using commercial simulation pack-
ages, so several authors have developed a simpler expres-
sion to estimate the flow-pressure relationship for
cannulae. The formalism describes the performance of a
cannula with a single number. Originally described by
Montoya et al.,6 the M-number of a cannula is similar to
the concept of impedance, so that a higher M-number is
experimentally assigned to a cannula that has higher
pressures for a given flow. Sinard et al.7 explored selected
extracorporeal cannulae (venous and arterial) and
derived their M-numbers experimentally. Kinks and
occlusions of side holes increased the M-number and the
addition of drainage holes or shorter cannula length
lowered the M-number. Delius and colleagues8 used the
M-number concept to describe non-circular cannulae
and found that their performances varied wildly, even
for similar cross-sectional area.
The ideal cannula design
Desirable cannula criteria
Cannula design has to focus on maximizing flow while
causing minimal damage to blood. A general cannula
and some of its features are shown in Figure 2.
Materials. The material of a cannula influences its flex-
ibility and consistency of shape. Cannulae that are too
Perfusion 28(2)
flexible may kink (a small kink would significantly
increase the pressure needed to maintain flow – as per
Bernoulli’s law) or collapse, therefore, impeding the flow
or causing turbulence. Flexible cannulae are also more
difficult to insert. On the other hand, these cannulae can
adjust to the patient’s anatomy and cause less tissue dam-
age. Modern cannulae are manufactured from polyure-
thane that has high material strength at room temperature
and becomes more malleable at body temperature (this
aids insertion of the cannula).9 Wire reinforcement of
the cannula walls is used to reinforce specific compo-
nents and prevent kinking or collapse. Radio-opaque
materials allow confirmation of correct positioning.
Surface coating. Blood interacting with artificial surfaces
activates the coagulation and complement cascades, the
kalikrein-kinin system, leukocytes and platelets. Thus,
the surface of the cannula with possible coating is essen-
tial in preventing fibrin sheath and thrombus formation.
A small thrombus can have a significant effect on flow.
This effect is especially detrimental when positioned at a
narrower part of the cannula or over a drainage hole
where it occludes a large proportion of the flow
volume.9
Modern cannulae feature biocompatible coatings
that reduce activation of the clotting cascade. Heparin-
coated surfaces result in reduced complement and
inflammatory activation due to its anti-inflammatory
properties,10 but the development of heparin-induced
thrombocytopaenia (HIT) has led to the search for
alternatives.11 Bivalirudin coating has been suggested12,13
and para-methoxyethylamphetamine (PMEA) coating
was shown to decrease the inflammatory reaction –
when measured via bradykinin and monocytes – and to
have reduced complement activation due to lower
Kohler et al.
immunoglobulin adsorption.14 It may be inferior to
heparin in decreasing the activation of the alternative
complement pathway.15,16
Newer biocompatible surfaces have been developed
that more closely resemble the physiological endothe-
lium. These coatings have a hydrophilic outer layer and
some contain negatively charged groups to repel nega-
tively charged proteins and platelets and create a layer
between the blood and the artificial surface (for example
“Balance Biosurface” by Medtronic17 and “X Coating” by
Terumo18). Comparison of these biocompatible surfaces
with uncoated surfaces shows decreased platelet activa-
tion and increased platelet function.
Length. The cannula length is often determined by the
type of circuit used: central access uses shorter cannulae
that reach the main vessels through the chest wall,
whereas peripheral cannulae reach from the peripheral
insertion point to a central location, such as the right
atrium for drainage or reinfusion.
Shape. The shape of the cannula influences the flow
characteristics. Changes in cross-section (tapering), non-
circular cross-section, bends or otherwise irregular
shapes can dramatically change the flow velocity. There
are significant differences between arterial and venous
cannulae due to different physiological requirements.
Venous cannulae need to be able to support high
enough drainage flows to sustain adequate support, but
only relatively low negative drainage pressures are possi-
ble so that the vessel does not collapse. The collapse of
the vena cava with increased drainage suction hinders
drainage19 instead of improving it. This concept makes
the venous cannula diameter the limiting factor for over-
all flow. The large capacity veins allow larger diameter
venous cannulae to be inserted so that the total drainage
flow is still adequate. Venous cannulae also commonly
include side holes to improve drainage from several sites,
such as the inferior vena cava (IVC) and the superior
vena cava (SVC).
Another development is the use of self-expanding
cannulae, where the cannula is inserted and, once in-situ,
the mandrel (holding it at a smaller diameter) is removed
and the cannula expands to fit the vessel size. When used
for cardiopulmonary bypass, they were found to improve
flow speeds and reduce venous line pressures.20 The
disadvantage is the difficulty of removal, especially when
used for prolonged periods of time.
Arterial cannulae, on the other hand, are significantly
narrower due to the vessel size so that significantly higher
pressures have to be applied for adequate flow and high
flow velocities to arise in the cannulae. This means that
the arterial cannula provides a large resistance within the
ECMO circuit and, therefore, creates a pressure drop
across it. This high pressure flow becomes turbulent at the
117
step-wise increase in flow diameter when exiting the can-
nula into the artery and forms a jet. It was discovered that
the arterial reinfusion jet in veno-arterial ECMO (and
conventional bypass) can cause a stroke when athero-
emboli are loosened by the arterial jet damaging the aor-
tic wall. Potential vessel damage is reduced by the specific
design of the arterial cannula tip into a “diffuser tip”,
where the reinfusion jet widens (and, therefore, slows
down) and the addition of side holes returning blood into
the aorta.21 It was found that straight-tip cannulae are
associated with significantly more strokes than bent-tip
cannulae when used in cardiac bypass.22 Another design is
the angled funnel shape developed by White et al.,23 which
reduces the shear force applied on the aortic wall.
Peripheral arterial cannulae are not only significantly
longer, but also have a similar small diameter throughout
as the peripheral vessel at the insertion point is narrow.
Further tapering would only increase the resistance
across the cannula.
Generally, cannulae often have transitions in shape
or material out of necessity – these are usually smooth,
but, at times, may be stepped. These steps form targets
for turbulence and stagnation and, therefore, both hin-
der flow and predispose to thrombus formation within
the cannula. The development of stagnation points is
increased by increased step size and the presence of con-
tracting steps (i.e. narrowing the cannula), but decreased
by higher flow velocity and pulsatile flow.24
Side holes. Since sufficient venous drainage is impor-
tant for overall flow, venous cannulae often have side
holes to facilitate better drainage at lower negative pres-
sures. The side holes have been shown to decrease the
amount of overall mechanical stress on blood compo-
nents.25 They allow greater drainage flow, but create
local vortices and turbulence. Computational fluid
dynamics can be used to evaluate and quantify these
effects25,26 and lead to improved side hole placement, e.g.
the simulations showed that staggering the side holes
along the cannula minimised shear stress and improved
flow. Additionally, further investigations showed that
slanting the side holes further reduced turbulent distur-
bance to the flow (Figure 1).27
Double lumen. Double-lumen cannulae combine both
drainage and reinfusion into one. Here, the geometry of
the flow and configuration of side holes is even more
complicated as the two flows and the risk of re-circulation
have to be considered. Experimental and numerical stud-
ies of a double-lumen cannula showed that the shear
stress was higher in the drainage lumen and regions of
turbulence were found at the connection sites to tubing.5
Additional features (insertion/sidearms).
Cannulae inserted
into peripheral arteries may nearly occlude the vessel
118
volume and cause downstream ischaemia. To avoid this,
reperfusion lines can be incorporated into the cannula
(Figure 2d). These sidearms are significantly narrower
than the main cannula, therefore, have faster flow. The
higher chance of turbulence in this setting also raises the
likelihood of thrombus formation and blockage of the
reperfusion line.
Cannula comparison
In order to compare different cannulae and determine
the best choice for each situation, pressure-flow tables
are often used. These tables are usually established exper-
imentally and show the behaviour of the cannula with
varying flow speeds.
The advantage of these tables is that the necessary
flow can be estimated and the appropriate cannula cho-
sen before insertion. Most tables published in catalogues
show the pressure drop corresponding to a flow between
0 and 5 L/min.
In addition to pressure tables, the M-number for-
malism allows comparison of different cannulae by cal-
culating an effective resistance for each cannula. For
example, a practical application to ECMO cannulae
showed that the M-numbers for shorter, but narrower,
arterial cannulae were identical to the ones of longer,
wider, venous ones. As a result, the short and narrow
arterial cannulae were preferentially used for percuta-
neous cannulation.28
ECMO circuits and their cannulae
Veno-arterial ECMO
There are two varieties of veno-arterial ECMO – central
and peripheral.
Central ECMO is similar to cardiopulmonary bypass
and involves direct cannulation of the major vessels
(usually right atrium and aorta). Central ECMO can be
used when patients are not able to wean from bypass and
then the bypass cannulae are used for the ECMO cir-
cuit.29 Placement of central cannulae solely for ECMO
use is limited to patients with severe cardio-respiratory
failure, requiring high flows to achieve adequate perfu-
sion. In this case, longer cannulae can be chosen and tun-
neled through the chest wall, allowing the sternum to be
closed. This reduces the risk of infection and restriction
or movement of the cannula when moving the patient.
Peripheral ECMO can be used in patients who require
less than full cardiac support or in emergency settings
such as cardiopulmonary resuscitation (CPR). The cir-
cuit drains deoxygenated blood peripherally and returns
it into the descending aorta to perfuse the lower limbs,
but also the cerebral and upper limb vessels via retro-
grade flow.
Perfusion 28(2)
Usually, the main limitation on flow is the amount of
drainage through the venous cannula and design fea-
tures such as side holes can help to improve flow.
Advancing the drainage cannula into the right atrium
reduces the risk of collapsing the vessel around the can-
nula and results in better drainage flows,30 even though a
longer cannula is needed.
In this type of ECMO, the amount of flow necessary
depends on whether the heart is to be rested and on the
ability of the lungs to oxygenate. If the heart is to be
rested, the flow rate needs to be adequate to drain enough
blood to prevent dilatation of the ventricular cavities
and, at the same time, perfuse the myocardium and
brain.
Another option for cannulation is to use the axillary
artery for the return cannula – either directly or via an
interposition graft. The advantage of axillary cannula-
tion is that central support with antegrade flow and ade-
quate upper body oxygenation can be established while
avoiding a sternotomy. Additionally, the lack of athero-
sclerosis, even in patients with ileofemoral disease,
decreases the risk of emboli.31 Complications reported
with the technique are hypoperfusion of the ipsilateral
arm32 and damage to the artery - both reduced with the
use of an interposition graft.33
The ECMO circuit can be combined with an intra-
aortic balloon pump to increase support.34 The addition
of an intra-aortic balloon pump was recently shown to
possibly be damaging to coronary perfusion35 and may,
therefore, not be helpful.
If flow is not sufficient then a second venous cannula
may be inserted.36,37 Insertion of a second arterial can-
nula can decrease high infusion pressures. If this fails, a
conversion to central ECMO may be indicated.
Veno-venous ECMO
Veno-venous ECMO is used in patients requiring respi-
ratory support only, as deoxygenated blood is drained
and returned to the venous side of the circulation after
passing through a membrane oxygenator. It is, therefore,
only suitable if the cardiac function is adequate to pro-
vide the cardiac output needed. Two main concerns arise
with respect to cannulation: adequate flow and recircula-
tion (known as shunting), where a portion of the oxy-
genated blood from the reinfusion cannula is immediately
returned into the drainage cannula.38
Initial trials of veno-venous ECMO used multiple site
access. The femoro-jugular approach used a long venous
drainage cannula inserted through the femoral vein into
the IVC and a shorter return cannula inserted into the
internal jugular.39,40 Based on an early description of this
circuit arrangement that found high flow rates and low
levels of recirculation,41 a ten-year trial, investigating
ECMO as a therapeutic option for acquired respiratory
Kohler et al.
Figure 3. a) Left: Flow in double-lumen, veno-venous ECMO. b) Right: Indication of recirculation.
distress syndrome (ARDS), was performed using the fem-
oro-jugular approach.42 Jugulo-femoral ECMO was
thought to provide superior venous drainage – possibly
due to the shorter drainage cannula resulting in lower
resistance and the spherical geometry of the right atrium.
This advantage was thought to balance the disadvantage
of increased recirculation and Pranikoff et al. described
the use of this circuit in patients with respiratory failure.28
The least common option was the femoro-femoral
approach where a long cannula to reach the right atrium
for venous drainage was combined with a shorter one for
reinfusion into the contralateral femoral vein. This
arrangement was significantly limited in flow due to the
increased cannula resistance and was only used as an
experimental alternative.28
The recent approach has been to use a single cannula
that provides both drainage and reinfusion. Early on,
single-lumen, tidal-flow systems (alternating periods of
drainage and infusion through the same lumen) were
able to provide adequate support to support life.43,44
Tidal flow would result in significant turbulence with
high shear stress and stagnation points inside the can-
nula whenever flow direction was reversed.
The current technique is to use a single dual-lumen
cannula that incorporates both drainage and reinfusion
lumen into one unit. After insertion through the internal
jugular vein, it drains deoxygenated blood from the IVC
and SVC and returns oxygenated blood through a sepa-
rate lumen into the right atrium (Figure 3).
119
Cannulae for sale
Cannulae for central veno-arterial ECMO
These cannulae are shown in Table 1, Table 2, Table 3a
and Table 3b. When central veno-arterial ECMO is
established in an emergency, the bypass cannulae can
continue to be used to avoid the need for cannula
change; however, this requires them to perform both for
a longer period of time and in different circumstances.
The bypass cannulae are relatively short and have a large
diameter. This allows high maximal flow, but increases
the risk of dislodgement or movement when used long
term (Table 1).
The cannulae used in central access specifically for
central ECMO usually have wire reinforcement of the
cannula wall to prevent kinking. These specifically
designed arterial cannulae have a smaller diameter which
increases the pressure drop, but also multiple outlet holes
that reduce it (Table 2). Both bypass and designated
ECMO arterial cannulae have diffuser or curved tips to
reduce the damage to the arterial vessel wall. Central
veno-arterial ECMO uses 2-stage venous cannulae with
drainage holes near the tip in the IVC and an additional
drainage “basket” in the right atrium. This allows for a
larger diameter along more of the cannula and, there-
fore, increased maximal flow. Similar to the arterial
cannulae, the venous cannula walls are wire reinforced.
One-stage cannulae offer a simpler option, which is
120 Perfusion 28(2)

Table 1. Central arterial cannulae

Company Size (circumference) Length (cm) Pressure drop for 24 Fr Options & features
at 4 L/min (mmHg)
Terumo1 21 Fr and 24 Fr 37 35 Wire reinforcement/thin-walled
26 Fr for L-series Side-hole exit ports
Diffusion/angled/straight/bevelled tip
Reverse angle tip
Soft flow and high flow options
Long or short tube length option
Retention ring
Medtronic2 18 to 24 Fr 30.5 20 Wire reinforcement
Side-hole exit ports
Multi-hole/dispersion/metal/bevelled tip/tapered/
angled tip
Pressure-monitoring port
Flexible option (higher pressure drop)
Maquet3 20 to 24 Fr 23 13 Wire reinforcement
Curved and straight tip
Edwards4 16 to 24 Fr 28 23 Wire reinforcement
Diffusion/angled/blunt tip
Intra-aortic emboli filter
1Terumo Cardiovascular Systems Corporation: http://www.terumo-cvs.com/doc/823392_CannulaeSternotomyCatalog_2011.pdf; 2Medtronic: http://
www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@cardio/documents/documents/2011-medtrnc-cannulae-catalog.pdf; 3Maquet: http://www.
maquet.com/productPage.aspx?m1=112599774495&wsectionID=112599774495&languageID=1; 4Edwards Lifesciences: http://www.edwards.com/
products/cardiac/Pages/CSCategory.aspx

Table 2. Central arterial cannulae specifically for ECMO

Company Size Length (cm) Pressure drop for 20 FR Options & features
at 4 L/min (mmHg)
Terumo1 10 to 26 Fr 15 60 See Table 1
Wire-reinforced, retention ring, various tip
options
Medtronic2 15 to 24 Fr 18 40 Bioactive coating, wire-reinforced, multiple
outflow holes
Maquet3 See Table 1
1Terumo Cardiovascular Systems Corporation: http://www.terumo-cvs.com/doc/823392_CannulaeSternotomyCatalog_2011.pdf; 2Medtronic: http://
www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@cardio/documents/documents/2011-medtrnc-cannulae-catalog.pdf; 3Maquet: http://www.
maquet.com/productPage.aspx?m1=112599774495&wsectionID=112599774495&languageID=1

easier to insert, but only drains blood from the right
atrium (Table 3a and Table 3b)
Cannulae for peripheral veno-arterial
ECMO
These cannulae are shown in Tables 4 and 5. The vessel
size at the insertion site is significantly smaller for the
arterial cannulae and the cannula diameter is reduced
compared to the central ones. This, combined with the
increased length, creates a higher pressure drop across
the cannula. A specific feature of peripheral arterial can-
nulae is the presence of reperfusion lines that aim to pre-
vent leg ischaemia by providing perfusion to the lower
limb (Table 4). The peripheral venous cannulae are
longer than their central counterparts, extending up into
the IVC and usually have several side holes along their
length for improved drainage. Most cannulae have thin
wire-reinforced walls to prevent kinking and some are
2-stage models that extend into the SVC. The long
extended tip is narrower than the body of the cannula,
giving it a tapered shape (Table 5).
Cannulae for veno-venous ECMO
Currently, one of the new methods of access used for
veno-venous ECMO is a dual-lumen, single cannula
that is inserted into the SVC via the internal jugular
vein. The walls are wire-reinforced and have drainage
side holes for both SVC and IVC. The reinfusion hole
Kohler et al. 121

Table 3a. Two-stage venous cannulae

Company Size Length (cm) Pressure drop for 32 Fr Options & features
at 4 L/min (mmHg)
Terumo1 28 to 36 Fr 39 5 Wire-reinforced, two-/three-stage
10 (malleable) Malleable
Lighthouse tip, bullet tip
Proximal collection holes
Internal flow directors
Biocoating
Medtronic2 28 to 36 Fr 38 6 Wire-reinforced, two-/three-stage
4 (oval body) Multi-port tip
Atrial baskets
Oval body
Thin walls (29 Fr)
Maquet3 32 to 36 Fr 40 5 Wire-reinforced, two-stage
Lighthouse/bullet tip
Slim shape with decreased resistance
Edwards4 29 to 36 Fr 37 6 Wire-reinforced, three-stage with dual
atrial basket/two-stage
Lighthouse tip
Multiple drainage holes
Low profile body
1Terumo Cardiovascular Systems Corporation: http://www.terumo-cvs.com/doc/823392_CannulaeSternotomyCatalog_2011.pdf; 2Medtronic: http://
www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@cardio/documents/documents/2011-medtrnc-cannulae-catalog.pdf; 3Maquet: http://www.
maquet.com/productPage.aspx?m1=112599774495&wsectionID=112599774495&languageID=1; 4Edwards Lifesciences: http://www.edwards.com/
products/cardiac/Pages/CSCategory.aspx

Table 3b. Single-stage venous cannulae

Company Size Length (cm) Pressure drop for Options & features
32 Fr at 4 L/min
(mmHg)
Terumo1 24 to 40 Fr 41 15 Wire-reinforced
52 (atrial cannula) Light-house/bullet/open tip, tip with side ports
Malleable
Biocoating
Medtronic2 26 to 40 Fr 38 15 Wire-reinforced
51 (atrial cannula) Multi-port/swirl tip, right-angle metal tip
Right-angle cannula
Malleable
Inflatable cuff
Different connection sizes (1/2 and 3/8)
Maquet3 12 to 40 Fr 40 20 Wire-reinforced
Lighthouse/bullet/pilot tip, straight/right-angle tip
Edwards4 24 to 36 Fr 40 16 Wire-reinforced
Lighthouse/angled tip,
Malleable
Thin wall design
1Terumo Cardiovascular Systems Corporation: http://www.terumo-cvs.com/doc/823392_CannulaeSternotomyCatalog_2011.pdf; 2Medtronic: http://
www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@cardio/documents/documents/2011-medtrnc-cannulae-catalog.pdf; 3Maquet: http://www.
maquet.com/productPage.aspx?m1=112599774495&wsectionID=112599774495&languageID=1; 4Edwards Lifesciences: http://www.edwards.com/
products/cardiac/Pages/CSCategory.aspx
122 Perfusion 28(2)

Table 4. Peripheral arterial cannulae

Company Size Length (cm) Pressure drop for 24 Fr Option & features
at 4 L/min (mmHg)
Terumo1 20 to 24 Fr 24 50 Femoral or central use
Movable suture ring
Maquet2 15 to 29 Fr 38 to 55 32 Wire-reinforced
Side holes
Luer lock for reperfusion catheter
Hardened proximal cannula body
Bioline coating
Edwards3 16 to 24 Fr 24 45 Wire-reinforced,
Thin wall
Flexible tip
1Terumo Cardiovascular Systems Corporation: http://www.terumo-cvs.com/doc/823392_CannulaeSternotomyCatalog_2011.pdf; 2Maquet: http://
www.maquet.com/productPage.aspx?m1=112599774495&wsectionID=112599774495&languageID=1; 3Edwards Lifesciences: http://www.edwards.
com/products/cardiac/Pages/CSCategory.aspx

Table 5. Peripheral venous cannulae

Company Size Length (cm) Pressure drop for 25 Fr Options & features
at 4 L/min (mmHg)
Terumo1 See Table 3a) & 3b)
Medtronic2 19 to 29 Fr 76 30 Wire-reinforced body
Extended side holes
Bicaval cannula
Maquet3 19 to 29 Fr 55 30 Wire-reinforced
Hardened proximal body
Alternating side holes
Bioline coating
Edwards4 18 to 28 Fr 87 45 Wire-reinforced
Extended drainage holes, separate
drainage holes for SVC and IVC
Thin wall design
1Terumo Cardiovascular Systems Corporation: http://www.terumo-cvs.com/doc/823392_CannulaeSternotomyCatalog_2011.pdf; 2Medtronic: http://
www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@cardio/documents/documents/2011-medtrnc-cannulae-catalog.pdf; 3Maquet: http://www.
maquet.com/productPage.aspx?m1=112599774495&wsectionID=112599774495&languageID=1; 4Edwards Lifesciences: http://www.edwards.com/
products/cardiac/Pages/CSCategory.aspx

Table 6. Double-lumen veno-venous ECMO cannulae

Company Size Length (cm) Pressure drop at 4 L/min Options & features
(mmHg)
Avalon Elite1 20 to 31 31 110 (31 Fr infusion) Kink-resistant material, wire-reinforced
30 (31 Fr drainage) Radio-opaque
Deflectable inner membrane
Distal and proximal drainage ports
Novaport2 18 to 24 Fr 27 Not available Kink-resistant
Wire-reinforced
Heparin coating
OriGen3 23 to 32 20 to 30 140 (13 Fr infusion) Wire-reinforced
30 (13 Fr drainage) Separated drainage and infusion ports
1Avalon Laboratories: http://www.avalonlabs.com/html/pulmonary_support.html; 2Novalung GmbH: http://www.novalung.com/en_products_and_
services_novaport_twin.html; 3OriGen Biomedical: http://www.origen.com/files/en/user/cms/data-sheet-lumen-catheter.pdf
Kohler et al.
needs to be aimed at the tricuspid valve, which requires
accurate positioning using fluoroscopy or ultrasound.
There are three commercially available options outlined
in Table 6.
For single-lumen, veno-venous ECMO, normal
peripheral venous cannulae can be used as described
above.
Conclusion
This paper reviewed the main physical principles behind
the practical problems relating to cannulae and how
these apply to the design of ECMO cannulae. The under-
standing of basic principles can improve cannula selec-
tion and development. The features of currently available
commercial options are reviewed.
Acknowledgments
The figures in this article were commissioned by
Papworth Hospital and created by Media Studios at
Addenbrookes Hospital (which is associated with
Papworth).
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Conflict of interest statement
The authors have no conflict of interest to declare.
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