Double, triple and quadruple cannulation for veno-arterial extracorporeal membrane oxygenation support: is there a limit?

Each cannulation strategy for venoarterial extracorporeal membrane oxygenation (VA ECMO) has distinct benefits and drawbacks. In this article, various cannulation strategies including their indications are discussed. The gold standard for cannulation involves peripheral, percutaneous double cannulation utilizing the patient's femoral vein and artery. In emergency situations under mechanical resuscitation, a simple and fast cannulation technique is crucial to reestablish circulation. This is usually performed percutaneously utilizing the femoral approach. However, in cases of anticipated long-term support, such as while awaiting cardiac transplantation, more sophisticated cannulation techniques (e.g., internal jugular vein to left axillary artery, left axillary artery for neuroprotection) are necessary to facilitate mobilization and physical conditioning on VA ECMO. More complicated are cases involving combined respiratory and cardiac failure requiring dual organ support or triple cannulation with an additional venous return cannula resulting in a veno-arterio-venous (VAV) configuration. Cases with left ventricular stasis with need for unloading are also highly demanding. Unloading the left ventricle (LV) can be performed in numerous ways, described elsewhere in this issue. However, one particular mode of unloading the LV is described as a stepwise and cost saving bridge to a durable paracorporeal left ventricular assist device in patients with an uncertain prognosis, which involves implantation of Berlin Heart EXCOR cannulas with temporary right heart support as an example of quadruple cannulation.