Table 3.

Pros and cons of cannula configuration

Cannulation strategy	Pros	Cons
Standard configurations
Venovenous (2 sites)
Femoral–femoral veins	•Ergonomically convenient during emergent bedside cannulation	Femoral vein risks∗ •Femoral vessels difficult to access because of depth from the skin •Wires can kink and be difficult to dilate because of the habitus •Pannus needs to be retracted
		•Imaging required to prevent recirculation •Exposing both groin sites difficult with large pannus •IVC crowded by cannulas
Femoral–internal jugular veins	•RIJ in line with SVC •Easier to retract pannus away from 1 groin site	LIJ risks† •LIJ requires imaging because of risk of innominate vein injury during dilation or cannulation
		•Femoral vein risks∗ •Risk of recirculation •Closer to tracheostomy site
Femoral–left subclavian vein	•Cannula does not move with neck ROM •Site further from tracheostomy	Left subclavian vein risks‡ •Left subclavian requires imaging to prevent venous or cardiac injury during dilation or cannulation
		•Femoral vein risks∗ •Risk of recirculation
Venovenous (dual lumen)	•Single site •Frees up peripheral site	•Real-time imaging to position •Limited ECMO flows
Internal jugular vein	•RIJ easy to place	•LIJ risks† •Real-time imaging to prevent cardiac injury by cannula •Neck cannula moves with ROM
Left subclavian vein	•Flows not affected by neck ROM •Site further from tracheostomy	•Left subclavian risks‡ •Requires experienced cannulator and live imaging
Configurations for extra flow
Veno-venovenous (VVV)	•Capacity for increased flow	•Needs imaging to prevent recirculation
Femoral–internal jugular veins, left subclavian	•RIJ preferred over LIJ	•Increased risk of recirculation Left subclavian vein risks‡ •Left subclavian requires imaging to prevent venous or cardiac injury during dilation or cannulation Femoral vein risks∗ •Femoral vessels difficult to access because of depth from the skin •Wires can kink and be difficult to dilate because of habitus •Pannus needs to be retracted
Femoral–internal jugular vein, femoral vein	•Can use RIJ or LIJ	•Femoral vein risks∗ LIJ risks† •LIJ requires imaging because of risk of innominate vein injury during dilation or cannulation
Femoral–left subclavian veins, femoral vein	•Flows not affected by neck ROM •Site further from tracheostomy	•Left subclavian risks‡ •Femoral vein risks∗
Venovenous (2 sites)
Femoral–internal jugular veins with extra-large cannula	•RIJ in line with SVC •Easier to retract pannus away from 1 groin site	•Larger cannula more technically challenging to place •Femoral vein risks∗ •Risk of recirculation •Potential LIJ risks†
DL–femoral vein (VV-VDL) Upper body DL with additional femoral venous drainage line	•Use RIJ, LIJ, or left subclavian •Frees up peripheral site •Can be easily converted to standard DL configuration when flow requirements decrease	•Real time imaging to position •Potential LIJ risks† •Potential left subclavian risks‡ •Femoral vein risks∗

IVC, Inferior vena cava; RIJ, right internal jugular vein; SVC, superior vena cava; LIJ, left internal jugular vein; ROM, range of motion; ECMO, extracorporeal membrane oxygenation; DL, dual lumen; VV-VDL, venovenous-veno dual lumen.

^∗Femoral vein risks.

^†LIJ risks.

^‡Left subclavian vein risks.