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Observational Study
. 2025 Jun;49(6):1012-1020.
doi: 10.1111/aor.14961. Epub 2025 Jan 27.

Impact of Cannulation Strategy and Extracorporeal Blood Flow on Recirculation During Veno-Venous Extracorporeal Membrane Oxygenation

Jan-Steffen Pooth  1 , Jil Kristin Förster  2   3 , Christoph Benk  2 , Patric Diel  2 , Sam Joé Brixius  2 , Sven Maier  2 , Alexander Supady  4 , Tobias Wengenmayer  4 , Dawid Leander Staudacher  4 , Gerd-Walter Haimerl  3 , Martin Czerny  2 , Julia Benk  2
Affiliations
Observational Study

Impact of Cannulation Strategy and Extracorporeal Blood Flow on Recirculation During Veno-Venous Extracorporeal Membrane Oxygenation

Jan-Steffen Pooth et al. Artif Organs. 2025 Jun.

Abstract

Introduction: Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is increasingly used in the treatment of severe respiratory failure. Despite a significant increase in the worldwide use of extracorporeal lung assist devices recirculation remains a common complication and is associated with a reduced effectiveness of ECMO support and increased hemolysis. In this observational study we aimed to investigate the impact of cannula configuration and extracorporeal flow on recirculation.

Materials and methods: An observational retrospective study was performed, which included all patients, who received V-V ECMO and recirculation measurements at the University Medical Center Freiburg between August 2021 and June 2023. Recirculation and extracorporeal flow were determined using ultrasonic indicator dilution technology. Patients were divided into subgroups according to their type of cannulation (dual lumen single-site vs. bifemoral vs. femoro-jugular).

Results: A total of 215 recirculation measurements in 47 patients were performed. Dual lumen single-site cannulation was associated with significantly lower recirculation rates (8.7% [0.0; 12.0]) compared to single lumen dual-site cannulation (femoro-jugular: 17.6% [0.0; 25.8]; bifemoral: 27.9% ± 13.4%). In addition, a positive linear correlation was observed between extracorporeal flow and recirculation in all subgroups. Recirculation increased significantly with rising extracorporeal flow in all subgroups.

Conclusion: Recirculation is a common complication in V-V ECMO and can lead to a reduction of ECMO effectiveness. Particular attention should be paid to optimal positioning of the cannulas in patients with more than one cannula. The ultrasonic indicator dilution method is a simple and quick method for measuring recirculation in V-V ECMO and can be used at an early stage if effectiveness decreases.

Keywords: ECMO; acute respiratory distress syndrome; cannula; extracorporeal circulation; recirculation; ultrasound dilution method; venovenous extracorporeal membrane oxygenation.

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Conflict of interest statement

M.C. is a consultant to Terumo Aortic, Medtronic, Endospan, and NEOS, received speaking honoraria from Cryolife‐Jotec, and is a shareholder of TEVAR Ltd. and Ascense Medical. J.S.P., S.J.B., and C.B. are part‐time employees of Resuscitec GmbH, Freiburg, Germany, which is a start‐up company from the University Medical Centre Freiburg. A.S. received speaker's honoraria and research grants from CytoSorbents, speaker's honoraria from Getinge and AstraZeneca, and consulting honoraria and travel support from ArtCline.

Figures

FIGURE 1
FIGURE 1
Measurement setup for determining recirculation (A). Schematics (B–D) show the cannula position and blood flow during dual lumen single‐site cannulation (B), femoro‐jugular cannulation (C) and bifemoral cannulation (D). [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 2
FIGURE 2
Average distribution of recirculation rates between cannulation groups. Red dot represents mean; **p < 0.01; ***p < 0.001. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 3
FIGURE 3
Comparison of bifemoral cannulation with bicaval dual lumen cannulation in one patient; **p < 0.01. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 4
FIGURE 4
Impact of ECMO flow on recirculation within the different cannulation groups. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 5
FIGURE 5
Effect of duration of ECMO in days on recirculation. [Color figure can be viewed at wileyonlinelibrary.com]
See this image and copyright information in PMC

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