Table 1.

Avalon Elite cannula insertion

• Time‐out • Patient in slight Trendelenburg position • Placement of horizontal back roll at the level of the scapulae with modest neck extension • The patient is prepped and draped under sterile conditions • Sterile preparation of the equipment on a back table • Systemic heparinization is administered (5000 IU) • Checklist verification • Puncture of right IJV under US visualization • Advancing guidewire (0.038″ × 210 cm) under fluoroscopy and TTE guidance, alternatively portable chest X‐ray sequence can be used to confirm adequate positioning in absence of fluoroscopy • Guidewire must follow a perfectly straight line, reaching the IVC in the mid‐abdomen (in absence of fluoroscopy, the position can be reliably verified with TTE subcostal views and portable chest X‐ray) • Progressive dilation of the skin entry site with dilators 10‐30 Fr. • Dilators are advance smoothly through the insertion site for a few cm (3‐5) to obtain proper dilatation of skin incision and venipuncture. • When the biggest dilators are utilized, the skin entry site requires to be enlarged with a surgical scalpel to allow smooth sliding of dilators removing any resistance to advancement at the skin entry site • The placement of the guidewire is reconfirmed by imaging to ensure the adequate position of the cannula deep into the IVC. • The Avalon Elite cannula is primed with heparinized saline and advanced over the guidewire under imaging guidance. • The tip of the cannula should be located approximately 5 cm below the right hemidiaphragm to ensure that the inflow port, which is at 10 cm from the tip, is positioned in the right atrium. • Location of the inflow port in the right atrium with jet anteriorly directed towards the tricuspid valve is confirmed by TTE imaging • Once the proper position and orientation of the cannula are obtained, the two attachment ports are connected to the ECMO circuit with meticulous deairing. It is recommended that tubing from the ECMO circuit is marked with blue tape to identify the outflow line carrying deoxygenated blood (from the patient to the oxygenator) and with red tape for the return inflow line carrying oxygenated blood (from the oxygenator to the patient). Red tubing is connected to cannula inflow (marked by an arrow pointing to the patient) and blue tubing is connected to cannula outflow (marked by an arrow pointing away from the patient) • The cannula needs to be positioned to the side of the neck maintaining the inflow port anteriorly to obtain the appropriate orientation of blood inflow in the right atrium towards the tricuspid valve • Blood flow is initiated at a slow rate to avoid sudden intravascular volume shift that would cause sudden hypotension. It is crucial to notice the difference between bright blood flowing in the anterior port compared to dark blood flowing in the posterior port. • Appropriate securing of the cannula to the skin is extremely important to avoid catheter's migration and rotation. • We apply to stitches that after being tied to the skin are looped around each one of cannula ports passing in the “crotch” between the two ports

Note: Technical tips of cannulation: The procedure requires the presence of two operators familiar with the use of the cannula and its insertion kit. It is important to prepare surgical instruments, tubing clamps, and all the needed items (Table 2). The patient is routinely cross‐matched for two units of packed red blood cells.

Abbreviations: ECMO, extracorporeal membrane oxygenation; IJV, internal jugular vein; IVC, inferior vena cava; TTE, transthoracic echocardiogram; US, ultrasound.

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