Wire puncture technique for placement of perfusion sheath during venous-arterial extracorporeal membrane oxygenation

Venous arterial extracorporeal membrane oxygenation (VA ECMO) is used to support the circulation during cardiovascular collapse. The main complications from this procedure are vascular and include limb ischemia secondary to the large bore arterial cannula that restricts flow to the lower extremity. Placement of an antegrade (perfusion) sheath can mitigate ischemic complications but is often challenging when an existing arterial cannula is present, when ultrasound imaging is suboptimal and in the setting of peripheral vascular disease, obesity and during emergent cannulations. Although surgical cut down remains an option, full dose anticoagulation and the critical status of the patient often require a less invasive alternative. We have found that a wire puncture technique using a 0.035-inch wire placed via the contra lateral femoral artery into the ipsilateral superficial femoral artery provides a reliable anatomic landmark for wire puncture and is a simple method for consistent placement of an antegrade sheath. Herein, we describe this technique with a recent critically ill patient requiring VA ECMO for cardiopulmonary resuscitation (eCPR) during acute myocardial infarction.