**5. Implementation of ECPR**

Institution of ECMO in adult patient with CA is challenging and should be performed by an expert specialized in percutaneous ECMO cannulation [47, 48]. Cannulation can be done in various locations including femoral vessel, internal Jugular vein (IJV)-femoral artery, femoral vein-subclavian artery, or IJV-subclavian artery [49]. The femoral vessels are most common and most appropriate for cannulation as it is easiest to locate the femoral vessels blindly with the pulse guidance, under Doppler ultrasound guidance as well as surgically even in the absence of pulse and also with ongoing CPR as groins are away from site of resuscitation and more

**Figure 3.** *Cannulation technique in ECPR.*

*Overview of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support… DOI: http://dx.doi.org/10.5772/intechopen.105838*

space is available to work compared to subclavian artery and axillary arteries that are very close to the site of CPR and always crowded. Percutaneous technique is easier and quicker and does not require surgical skills. However, percutaneous technique is fraught with the risk of inability to puncture or cannulate the vessel [50]. With open surgical cannulation, it is easier to locate and cannulate the vessel of interest, but it significantly impacts procedure time [51]. Further, availability of cardiac or vascular surgeons for the exposure of femoral vessels and need for appropriate setup and instruments are additional hurdles for open surgical cannulation. Although, in pediatric patients with ECPR, open surgical cannulation of carotid artery and internal Jugular vein is the standard of care, in adults with CA, percutaneous cannulation of femoral vessels is preferred as time is the essence. But, if this fails, then an open surgical technique must be used [52]. In ECPR, selection of appropriate size cannulas is especially important as the size of cannula determines how efficiently the ECPR will work. The largest possible venous and arterial cannula appropriate to provide >2.5 L/ m2 flow with injuring the vessels should be selected. For an adult patient, 23–25 Fr venous drainage cannula and 17–19 Fr. arterial cannula are sufficient for adequate flow [41, 53]. The venous cannula is extended up to the right atrium or inferior vena cava and right atrial junction, and the arterial cannula is brought to the descending thoracic aorta (**Figure 3**).
