A Simple Technique for Difficult Atriocaval Cannulation

To the Editor:

As generally performed with a large, dual-stage venous catheter, right atriocaval cannulation provides enough venous return for most cardiac surgical procedures. In some cases, insertion of the cannula tip into the inferior vena cava is difficult or impossible due to a variety of causes, such as a large Eustachian valve, a persistent Chiari network, or atrial adhesions. Forced positioning of the catheter is harmful and may lead to damage and hazardous bleeding complications in the right atrium, inferior vena cava, or both. Transesophageal ultrasonic guidance or bicaval cannulation seems to be appropriate in such situations, but it too can be difficult and takes time. We describe a simple technique for using the dual-stage catheter and thereby avoiding bicaval cannulation.

In regular cardiopulmonary bypass surgery, we use a single dual-stage cannula (Terumo® Cardiovascular Systems; Tokyo, Japan). If insertion of the venous catheter into the inferior vena cava is not possible and we do not want to perform bicaval cannulation, we cut the dual-stage cannula 5 mm distal to the basket (Fig. 1, arrow) and introduce the catheter into the right atrium. We place the tip of the cannula next to the inferior vena cava. The cannula is then secured by means of 2 purse-string sutures. We used this technique, which actually corresponds to the “old” technique of atrial cannulation,¹ in 12 patients who were undergoing coronary artery bypass surgery, aortic valve replacement, or both. We had an uneventful intraoperative course in all patients—in particular, no displacement of the atrial cannula, no air aspiration, and no difficulty in venous backflow. The described technique may not be applicable in complex cardiac surgery procedures; however, it is a simple technique that avoids bicaval cannulation in regular cases.

Fig. 1 The proximal and distal parts of the cut Terumo® dual-stage venous cannula. The arrow marks the cutting point, 5 mm distal to the basket.

Peter Matt, MD
Thierry Carrel, MD
Wolfgang Brett, MD
Division of Cardiac Surgery, University Hospital, Basel, Switzerland