Ambulatory venoarterial ECMO via right subclavian artery and internal jugular vein cannulation: a novel technical approach to bridge-to-transplant.

Standard femoral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) severely limits patient mobility. We introduce a novel "femoral-free" Ambulatory Subclavian-Jugular V-A ECMO technique to maximize rehabilitation capabilities. We employed a subclavian-right internal jugular configuration. Initially, a vascular graft anastomosis was used for arterial return, but this resulted in upper limb swelling. Subsequently, we modified our approach as a technical refinement: inserting a 17-Fr reinfusion cannula directly into the right subclavian artery with a 6-Fr distal perfusion catheter to prevent arm ischemia. For drainage, a long venous cannula was inserted into the right internal jugular vein and advanced to the inferior vena cava. Furthermore, inserting the drainage cannula via the internal jugular vein in a retrograde fashion, contrary to the conventional approach, provided adequate venous drainage for ECMO support. This optimized configuration maintained stable ECMO flow (3.5-4.0 L/min) and enabled active bedside rehabilitation comparable to that of dual-lumen veno-venous ECMO. Notably, no right arm swelling was observed with the direct cannulation method in our single case, although this observation requires further validation. This "femoral-free" approach is a feasible and effective strategy for patients requiring prolonged V-A ECMO support, such as bridge-to-transplant candidates, by facilitating continuous active physical therapy. Direct cannulation may represent a promising technical refinement to minimize local limb complications, though comparative conclusions cannot be drawn from this limited experience.