Strategies for appropriate positioning and repositioning the Avalon ECMO cannula in a 17-year-old with left hepatic vein malposition

Introduction: Extracorporeal membrane oxygenation (ECMO) is a well-recognized therapy in children with refractory hypoxia. Different cannulas have been used with reported complications with placement, such as cardiac perforation, and multiple reports focusing on avoiding this. However, strategies to avoid hepatic vein cannulation and reposition when it occurs are not well described. Case report: Here, we report a case where a 27-Fr Avalon bicaval double lumen cannula in the left hepatic vein was successfully repositioning using serial chest X-rays (CXR) and transthoracic echocardiography (TTE) in a 17-year-old female. Discussion: While venovenous (VV) ECMO is preferred by many, placement of the Avalon catheter, a cannula available for VV ECMO, may be challenging due to migration or positioning issues. Specific techniques of wire and catheter advancement as well as confirming wire position in the infra-hepatic inferior vena cava can help ensure appropriate positioning while avoiding hepatic vein cannulation and enabling successful repositioning when it occurs. Conclusion: Wire position in the infra-hepatic inferior vena cava helps ensure safe and appropriate Avalon cannula position and placement. The Avalon cannula can be successfully repositioned from the left hepatic vein by retracting the cannula, reinserting the wire and introducer together, and then manipulation techniques using serial CXR and TTE.