Emergency veno-arterial extracorporeal membrane oxygenation cannulation through the femoral vein with a pre-positioned inferior vena cava filter: A case report

Abstract

BACKGROUND

Acute pulmonary thromboembolism is a complication of venous thrombosis. Extracorporeal membrane oxygenation (ECMO), an effective rescue measure for rapid hemodynamic recovery, can be used in patients for whom thrombolysis therapy has failed.

CASE SUMMARY

This case report describes an extreme rescue process for a patient with a preset inferior vena cava (IVC) filter in a relatively economically underdeveloped area with an insufficient supply of consumables. In an emergency, veno-arterial ECMO was successfully initiated by intubation through the IVC filter to the right atrial opening without displacement of the filter during the entire process.

CONCLUSION

This study demonstrates that in resource-limited settings, femoral vein cannulation for veno-arterial ECMO is a feasible and safe option for patients with pre-implanted IVC filters.

Key Words: High-risk pulmonary embolism; Venous-arterial extracorporeal membrane oxygenation; Inferior vena cava filter displacement; Thrombolysis therapy; Case report

Core Tip: Managing pulmonary thromboembolism in critically ill patients with pre-positioned inferior vena cava filters poses significant challenges, especially in resource-limited settings. This case report describes the successful initiation of veno-arterial extracorporeal membrane oxygenation using femoral vein cannulation through a 32 mm inferior vena cava filter without complications. Careful pre-procedural evaluation ensured safe extracorporeal membrane oxygenation support and filter integrity. Our findings provide a feasible emergency strategy for intensive care physicians facing similar scenarios, offering a life-saving approach when conventional access is limited.

INTRODUCTION

Pulmonary thromboembolism (PTE) is a life-threatening condition often caused by lower extremity deep vein thrombosis (DVT), heart disease, and tumors. In less-developed regions, PTE rescue success rates remain low due to limited resources and relatively high therapeutic costs. Tumors are independent risk factors for venous thromboembolism (VTE)[1], with solid tumors, particularly gastric cancer, posing a higher risk[2,3]. PTE is a serious complication of VTE, with 30-day mortality rates ranging from 25% to 65%[4,5]. Patients with obstructive shock have an even higher mortality, exceeding 50%[6]. The 2019 European Society of Cardiology Guidelines[7] recommend various rescue strategies for acute PTE, such as systemic thrombolysis, anticoagulation, catheter-directed therapy, and surgical thrombectomy. However, treatment failures may occur in certain cases. In cases where right ventricular dysfunction and hemodynamic instability persist after systemic thrombolysis and intraductal therapy, the guidelines recommend immediate implementation of temporary mechanical circulation to ensure complete cardiopulmonary support. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective rescue method that rapidly restores hemodynamics[8]. However, in some patients with pre-implanted inferior vena cava (IVC) filters to prevent DVT in the lower limbs, femoral vein intubation for extracorporeal membrane oxygenation (ECMO) is challenging due to the risk of filter displacement. The formation of a new thrombus around the filter can lead to more serious embolization events. This increases uncertainty during the treatment procedure and the insecurity of intensive care unit (ICU) physicians in decision-making. Consequently, the rescue time may be delayed and prolonged, potentially leading to an increased risk of fatality. In economically developed areas with advanced medical technology, internal jugular vein drainage cannula with appropriate external diameters and flow-matching requirements can be used to drain blood from the superior vena cava to the right atrium[9]. Alternatively, blood may be drained through the right atrium to the IVC opening using double jugular vein intubation guided by ultrasound[10]. However, in economically underdeveloped areas, where the supply of common ECMO consumables is limited and high-end materials are difficult to obtain, the development of this technology may be greatly restricted. Currently, there is extremely limited literature on ECMO venous intubation options for high-risk patients with PTE who are implanted with IVC filters but have failed thrombolysis. Here, we report a case in which the patient was successfully treated. Our experience may provide an emergency option for ICU physicians to perform intubation through the femoral vein access in patients requiring salvage ECMO with an IVC filter.

CASE PRESENTATION

Chief complaints

A 49-year-old female patient was diagnosed with gastric horn signet-ring cell carcinoma (cT3N1M0, stage IIIA). With no history of heart disease or contraindications to surgery, she underwent laparoscopic gastrectomy for gastric cancer, jejunojejunostomy, and abdominal chemical perfusion under general anesthesia. The surgery was performed at the gastrointestinal surgery department. The patient experienced dyspnea, sweating, tachycardia (132 beats per minute), hypoxemia (71%), and hemodynamic instability (73/42 mmHg) on the third postoperative day. The D-dimer level was 10.18 mg/L, which reference value was less than 0.5 mg/L. The patient was considered to be a high-risk PTE. Given the high risk of transport, computed tomography pulmonary angiography was abandoned. Instead, she was rushed to the interventional operating room for catheter-directed therapy. The main pulmonary artery and its distal branches were not shown by angiography (Figure 1).

Figure 1  The main pulmonary artery and its distal branches were not shown by angiography.

History of present illness

A 49-year-old female patient, she underwent laparoscopic gastrectomy for gastric cancer, jejunojejunostomy, and abdominal chemical perfusion under general anesthesia. The surgery was performed at the gastrointestinal surgery department.

History of past illness

History with gastric horn signet-ring cell carcinoma (cT3N1M0, stage IIIA). The patient had no history of heart disease.

Personal and family history

No family history.

Physical examination

The patient experienced dyspnea, sweating, tachycardia (132 beats per minute), hypoxemia (71%), and hemodynamic instability (73/42 mmHg) on the third postoperative day.

Laboratory examinations

The D-dimer level was 10.18 mg/L, which reference value was less than 0.5 mg/L.

Imaging examinations

The main pulmonary artery and its distal branches were not shown by angiography (Figure 1).

FINAL DIAGNOSIS

Intraoperative evidence revealed thrombosis of the left main pulmonary artery and its branches, as well as DVT in both lower limbs (Figure 1).

TREATMENT

The interventional doctor performed IVC filter implantation and pulmonary artery internal tube hemolysis. After systemic administration of 3000 U heparin, an IVC filter (WXF-32 IIIicium^® vena cava filter system) with a diameter of 32 mm was implanted at 0.5 cm from the renal vein opening. A catheter was then placed into the pulmonary artery thrombus, and 30 wu of urokinase was slowly injected locally after mechanical balloon thrombolysis. The patient was transferred to the ICU for further treatment including active anticoagulation, optimized use of vasoactive drugs, mechanical ventilation, and continuous renal replacement therapy. The doctor first administered an intravenous infusion of 20 wu urokinase first after 16 hours, followed by continuous intravenous infusion of 20 wu urokinase. However, hemodynamics remained unstable and the patient remained in critical condition with persistent pulmonary hypertension and unstable vital signs. It was not possible to re-transport for filter removal.

To save her life, after repeatedly confirming the absence of new thrombi around the filter and careful evaluation of the inherent physical conditions of the drainage cannula by bedside color Doppler ultrasonography, the ICU doctor chose the right femoral vein to insert a 20 Fr single-stage, disposable extracorporeal circulation femoral vein catheter at the 20^th hour from the patient’s onset (Changzhou Longlefu Medical Materials Co., Ltd.). The 45 cm intubation successfully reached the right atrial opening (Figure 2A), and ipsilateral femoral artery cannulation was successful. Rescue VA-ECMO was successfully initiated. Subsequently, vasoactive drugs were quickly stopped, and arterial oxygen partial pressure increased. Anticoagulation with low molecular weight heparin was given after ECMO withdrawal. Oral rivaroxaban was given for 3 months after discharge.

Figure 2 Imaging findings. A: The extracorporeal membrane oxygenation venous drainage catheter travels in the inferior vena cava through the hollow region of the filter, which is located at the L2 level; B: After extracorporeal membrane oxygenation weaning and removal of the venous drainage catheter, the inferior vena cava filter remained at the L2 level with no thrombus inside or outside the filter.

OUTCOME AND FOLLOW-UP

The patient’s hemodynamics returned to normal following the above intervention. A bedside abdominal X-ray showed that the filter remained at the L2 level without displacement and that the venous drainage catheter was running through the hollow area of the filter. After 5 days of VA-ECMO support, the patient was successfully removed from the machine. Computed tomography revealed no thrombosis in the IVC. No displacement was observed in the filter (Figure 2B). The extubation process did not affect the filter. The patient was transferred out of the ICU without tracheal intubation on the third day after VA-ECMO removal. After 6 months of follow-up, the patient was in good living conditions without complications.

DISCUSSION

The diagnosis and treatment of PTE have improved with the development of the global economy. It has been reported that the mortality rate of PTE in the Asian population has decreased in general[11]. The all-cause mortality rate of PTE in China also showed a significant downward trend from 2009 to 2015[12]. The northern part of Guizhou is characterized by heavy terrain, inconvenient transportation, and a relatively underdeveloped economy. In recent years, the rapid development of the regional economy has increased the level of emergency and critical care diagnosis and treatment in the region, and the rescue treatment ability of PTE in primary hospitals has significantly improved. The number of patients with a confirmed diagnosis of PTE increased from 2019 to 2022, whereas the mortality rate decreased steadily (Figure 3). Thrombolytic anticoagulation therapy, catheter-directed therapy, and surgical thrombectomy have gradually become standardized, and the number of patients treated with VA-ECMO has also increased. Owing to the lack of internal jugular vein cannula, femoral vein cannulation was selected as the only approach for ECMO venous drainage in our hospital. In the case of a life-saving emergency, there is a lack of experience regarding whether patients with a preset IVC filter can undergo femoral vein cannulation to initiate VA-ECMO. Related factors may include the diameter of the implanted filter, the outer diameter of the venous cannula, whether patients have thrombosis in the IVC around the filter, and the willingness of the family for rescue.

Figure 3 Mortality of patients diagnosed with pulmonary thromboembolism in the Affiliated Hospital of Zunyi Medical University from 2019 to 2022 (n1/n2). n1 represents the annual number of deaths and n2 represents the annual number of confirmed pulmonary thromboembolism cases.

This case is of a female who has lived in the plateau area for a long time, an environment that might increase the risk of VTE formation[13]. In contrast, solid gastric tumors increase the risk of PTE. After confirming PTE diagnosis, active thrombolysis and catheter-directed therapy were administered; however, both were ineffective. Continuous right ventricular failure caused hemodynamic failure. Extracorporeal cardiopulmonary support needed to be initiated as soon as possible, but the patient’s preset filter system in the IVC increased the concern of the critical care physician. Careful evaluation revealed that ECMO femoral vein intubation and the extubation process did not cause migration of the filter or thrombus, which successfully saved her life. The rescue process used in this case may provide a feasible reference for critical care physicians when performing ECMO intubation in patients with preset IVC filters.

There were some risks when the venous drainage cannula was routed through the IVC filter, including failed pass, displacement of the filter and vascular injury. In order to avoid these risks, it is necessary to evaluate the diameter of the filter aperture and the ECMO drainage cannula before operation. In this case, the aperture of the filter was 10 mm, and the outer diameter of the drainage cannula was 6.67 mm. The distance from the femoral vein puncture point to the filter was measured. During the operation, when the drainage catheter reached the filter, if it was blocked, it was withdrawn by 5 cm, adjusting the direction and slowly advancing the cannula again. After operation, the position of the filter was checked by ultrasound again.

We showed some key points of successful operation: (1) Adequate preoperative evaluation: Ultrasound evaluation of the diameter of the IVC, the location of the filter, and the absence of new thrombosis around the filter. Evaluation of the drain line outer and filter diameter, ensuring drain line Fr < IVC filter aperture; (2) Intraoperative attention points: Forcing through filters is not recommended. Encountering resistance, it is necessary to withdraw the catheter by 5 cm or more, adjust the direction and push the catheter again; and (3) Postoperative evaluation: The position of the filter was reviewed by bedside ultrasound and X-ray after operation.

CONCLUSION

In resource-limited areas, for patients with a pre-installed IVC filter but requiring initiation of rescue ECMO, a 20 Fr femoral vein catheter can reach the right atrial opening through the 32 mm diameter filter in the IVC, as confirmed by careful ICU evaluation. ECMO intubation and weaning had minimal effects on the filter. Our findings may provide a feasible reference for critical care physicians when performing ECMO intubation in this patient group.

ACKNOWLEDGEMENTS

The authors thank the patient and her family for their assistance.