Table 1

Malposition complications and respective solutions in Avalon cannula placement

ComplicationsTroubleshooting
A. Guidewire dislocation
Guidewire has not yet in the IVCGuidewire can be in the RV or the coronary sinus. Withdraw the guidewire and try advancing it slowly several time. Exchange a harder guidewire if necessary.
Guidewire is dislocated from the IVCAdvancing deeply the guidewire into the distal part of the IVC up to the iliac vein. Hold the guidewire properly when exchanging dilators and advancing the cannula over-the-wire.
Guidewire looping despite its distal part remains in the IVCRe-examining other echocardiographic views (parasternal RV inflow, subcostal four-chamber). Observing meticulously the entire pathway of the guidewire in bicaval subcostal view of TTE: make sure that the cephalad portion of the guidewire is not near the aorta and not pass through the tricuspid valve.
Advancing the cannula cautiously over-the-wire. Paying attention to the ECG monitoring to early detect premature ventricular complexes, change the echo view to multiple planes (including subcostal four-chamber view, parasternal short axis view) whenever malposition is suspected.
B. Cannula dislocation
Rotational dislocationFixed the cannula at the retromastoid region. Rotating the cannula to ensure the returning blood flow towards the tricuspid valve.
Longitudinal dislocationCan be detected on radiography. Withdraw and fixation if dislocated deeply. Recannulation depends on the type of more difficult dislocation (into hepatic vein, into coronary sinus or coronary artery compression).
  • IVC, inferior vena cava; RV, right ventricular; TTE, transthoracic echocardiography.