• Gennaro Martucci, Fabrizio di Francesco, Giovanna Panarello, Marcello Piazza, Jean de Ville de Goyet, and Antonio Arcadipane.
• Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy.
• Perfusion. 2021 Jan 7: 267659120987089.

IntroductionFemoral cannulation for veno-venous extracorporeal membrane oxygenation is challenging in infants because of the diameter of the vein.Case ReportProlonged ECMO support (67 days) was necessary for an 8-month-old (8 kg) girl with acute respiratory distress syndrome that was caused by H1N1 influenza. After 30 days on ECMO support and using a single 16 Fr double-lumen cannula (internal jugular vein), a second cannula was necessary to ensure adequate flow. This second 12 Fr single-lumen cannula was surgically placed through the right common iliac vein. An excellent flow profile was then achieved and ECMO continued successfully for 37 more days.DiscussionAs a lifesaving option, this double caval configuration successfully optimized the flow profile and oxygenation, outweighing the related risks.ConclusionIn small children, a surgical approach to the inferior vena cava can be considered safe, especially in those cases where there is a shortage of adequate cannulas, or when central venous access is difficult.

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