Bedside Popliteal Vein Cannulation for Simultaneous Plasmapheresis and Renal Replacement Therapy in the Prone Position

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To the Editor:

The COVID-19 pandemic has introduced challenging scenarios, necessitating a “thinking outside the box” approach for patients with profound respiratory failure requiring mechanical ventilation in the prone position (PrP). This is nicely demonstrated in the case by Montero-Cabezas et al whereby veno-venous extracorporeal membrane oxygenation (VV-ECMO) cannulation with a Crescent cannula (Medtronic) was performed with the patient in the PrP.¹ In this instance, as seen in Figure 1 of their manuscript, the patient’s head appears relatively accessible, and the procedure was able to be performed in the catheterization lab.¹

However, even more challenging and restrictive clinical situations exist. We have previously described such a case involving a heart transplant recipient with a body mass index of 40 kg/m² who required mechanical ventilation in the PrP due to severe COVID-19 related respiratory failure.² In this circumstance, a RotoProne system (Arjo) was used (Figure). Unlike conventional proning, patients can be easily turned and repositioned with the touch of a button, therefore requiring fewer personnel. Furthermore, this system allows for Trendelenburg and Reverse Trendelenburg positions. The patient was intolerant to supination due to severe arterial oxygen desaturation and was deemed to not be a candidate for VV-ECMO. Oliguric renal failure required urgent renal replacement therapy (RRT). Due to severe restriction of conventional central venous site access in the PrP within the RotoProne system (Figure), attention was turned to the popliteal vein (PV). The left PV was easily identified and accessed using real-time ultrasound. A 14-French 25-cm dialysis catheter was placed without apparent complications. Through this catheter, both continuous RRT and plasmapheresis (to attenuate cytokine storm syndrome) were performed in tandem for 72 hours, achieving normal flows without circuit alarms or clotting.² Although RRT via the PV has been previously reported, our experience is the first to describe bedside use of PV access for tandem plasmapheresis and RRT using a standard catheter and in a heart transplant recipient.^2,3

The COVID-19 pandemic has led to an increase in the rate of acute respiratory distress syndrome in intensive care units (ICUs) around the country, resulting in an increased use of mechanical ventilation in the PrP.⁴ Furthermore, RRT is needed in up to 25% to 30% of patients requiring ICU-level care.^4,5 Although the internal jugular vein is the preferred access site and cannulation in the PrP can be performed with high success rates, pneumothorax occurs 6% of the time.⁴ In the absence of conventional sites for urgent or emergently needed central venous access, especially when supination is not tolerated, the PV is an attractive option. Advantages include zero risk of pneumothorax and, in the setting of COVID-19, it is the furthest site from respiratory droplet or aerosol exposure.³ Furthermore, endotracheal tube dislodgement is minimized due to the lack of need to reposition the patient’s head for the procedure.⁴ Access should be obtained using ultrasound guidance and a tourniquet or pneumatic tourniquet, and/or the reverse Trendelenburg position can be used to accentuate the PV.  Longer catheter sizes may be needed, especially if the PV is small and optimal flow rates are not achieved during RRT.³ Alternatively, superficial femoral venous access in the PrP has been described, however, this is more technically challenging than the use of the PV.⁶

As with any procedure, the risks and benefits should be weighed. There is a theoretical risk of deep venous thrombosis as a result of cannulation of the PV; however, this risk has not been quantified and it is unclear if the risk is greater than that of conventional central venous access sites.³ We encourage providers to keep in mind that when central venous access is severely restricted in the PrP, the PV is an acceptable alternative for vasoactive medication administration, RRT, and plasmapheresis.

Affiliations and Disclosures

From the ¹Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas; USA; ²Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA; ³University of Utah, Division of Cardiovascular Medicine, Salt Lake City, Utah, USA.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Faris G. Araj, MD, Professional Office Bldg. 2 Suite 600, 5939 Harry Hines Blvd., Dallas, TX 75390-9252, USA. Email: faris.araj@utsouthwestern.edu; X: beaini_hadi

References

1. Montero-Cabezas JM, Janson JA, Al Amri I, Elzo Kraemer CV. Veno-venous extracorporeal membrane oxygenation cannulation in prone position. J Invasive Cardiol. 2024;36(1). doi:10.25270/jic/23.00093
2. Balakrishnan N, Zhang E, Carter S, Araj F. Use of the popliteal vein for dialysis and plasmapheresis in a proned cardiac transplant recipient with severe COVID 19 infection. Presented at: The Seventh Annual Donald W. Seldin, M.D., Research Symposium; April 21, 2022; Dallas, TX. Poster #059.
3. Adams E, Mousa AY. Achieving a popliteal venous access for renal replacement therapy in critically ill COVID-19 patient in prone position. J Vasc Surg Cases Innov Tech. 2020;6(2):266-268. doi:10.1016/j.jvscit.2020.04.003
4. Lussier BL, Pham DT, Ratti GA, Patel J, Mitchell BC, Chen C. Catheterization without supination-a series of 36 prone position internal jugular vein cannulations. Crit Care Explor. 2022;5(1):e0831. doi:10.1097/CCE.0000000000000831
5. Jewell PD, Bramham K, Galloway J, et al. COVID-19-related acute kidney injury; incidence, risk factors and outcomes in a large UK cohort. BMC Nephrol. 2021;22(1):359. doi:10.1186/s12882-021-02557-x
6. Ostroff M, Ismail M, Weite T. Achieving superficial femoral venous access in a critically ill COVID-19 patient in the prone position. J Vasc Access. 2022;23(3):458-461. doi:10.1177/1129729821989894

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