A 64-year-old man was admitted to the intensive care unit with acute distress respiratory syndrome (ADRS) due to H1N1 Influenza pneumonia. The patient required moderate doses of intravenous vasoactive drugs and mechanical ventilation to maintain hemodynamic and respiratory stability. Chest radiograph showed bilateral interstitial infiltrates. Gas exchange progressively deteriorated in spite of conventional ventilatory support. In this situation, veno-venous extracorporeal membrane oxygenation (ECMO) was implanted under guidance by transesophageal echocardiography (TEE). Cannulation was performed via femoro-jugular approach using a right femoral drainage cannula (25F) and a right jugular reinfusion cannula (21F). On day 8, during postural changes the patient developed sudden hypoxemia and low ECMO flow (Fig. 1). Negative pressure within the inlet cannula markedly increased. Urgent TEE demonstrated a thrombus located in the inferior vena cava directly opposite the tip of the drainage cannula leading to intermittent obstruction of the lumen. Anticoagulation was carefully optimized and the thrombus disappeared on a repeated echocardiogram.
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