Echo-guided bi-caval dual lumen ECMO catheter insertion (Avalon Elite®)

The Alfred ICU uses the Avalon Elite® Bi-Caval Dual Lumen Catheter for veno-venous ECMO support where single catheter internal jugular access is desired.  One advantage of this approach is the ability to mobilise the patient (compared with a 2 catheter approach with at least 1 catheter in the femoral vein). Blood is removed from both the SVC and the IVC, passed through an oxygenator and returned into the right atrium.  The returning blood flow is directed at the tricuspid valve.


Correct positioning is shown below:

Avalon Elite bicaval dual lumen cannula in correct position. From Hirose et al, 20012. (Click image for source)

Avalon Elite bicaval dual lumen cannula in correct position. From Hirose et al, 2012. (Click image for source)


Echocardiographic guidance during insertion is vital. In particular, echo can assist with correct placement of the guide wire into the IVC (as opposed to the hepatic vein). Echo will also guide the appropriate depth of insertion and rotational orientation of the catheter.

The brief video clips below illustrate how useful Echo really is!

(1) Guide wire in RA (TOE Bi-caval view):

(2) Guide wire incorrectly positioned in RV (TOE Bi-caval view):

(3) Guide wire correctly positioned in IVC bypassing the hepatic vein (TTE subcostal short axis view):

(4) Catheter in good position with delivery of oxygenated blood towards the RV apex in diastole (TTE subcostal 4 chamber view):

References and Links

  • Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation. J Cardiothorac Surg. 2012 Apr 20;7:36. doi: 10.1186/1749-8090-7-36. PubMed PMID: 22515939; PubMed Central PMCID: PMC3372439.

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4 comments on “Echo-guided bi-caval dual lumen ECMO catheter insertion (Avalon Elite®)
  1. Thanks for an interesting post.

    Bit of feedback – some longer ECHO clips would be great, these two-second ones make it a bit hard to see what’s going on!

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