Hepatic vein cannulation during veno-arterial extracorporeal membrane oxygenation

Excerpt

A 63-year-old man was admitted for severe cardiogenic shock, which developed in the setting of an advanced idiopathic dilated heart failure. Despite medical therapy including mechanical ventilation, noradrenaline and levosimendan, veno-arterial extracorporeal membrane oxygenation (ECMO) via a percutaneous femoral approach was initiated because of increased lactate levels and theoccurrence of acute kidney injury and hypoxic hepatitis. ECMO cannulation was ultrasound-guided using transthoracic echocardiography; the insertion of the venous multistage cannula was controlled up to the suprahepatic veins and inserted without visual control for 5 cm to reach the right atrium. The ECMO worked uneventfully with a blood flow of 3.8 L/min and the circuit was anticoagulated using unfractionated heparin. The patient was rapidly extubated and organ dysfunctions and hyperlactatemia rapidly improved. A thoraco-abdominal CT scan was performed at day 4 before the implantation of a left ventricular assistance device (LVAD); surprisingly, the venous cannula had entered the right hepatic vein (Fig. 1), without organ injury and with liver within normal values. The cannula was removed only at day 9, when the LVAD was eventually inserted; the total fluid balance since ICU admission to LVAD was − 3100 mL. The tip of the venous cannula was twisted and thrombus was visible (Supplemental Fig. 1). The evolution of the patient was favourable. This case highlights the importance of complete ultrasound-guided ECMO cannulation and post-procedure imaging to avoid malpositioning and complications.

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