A 70-year-old woman hospitalized with postcholecystectomy after acute perforation of cholecystitis suffered cardiopulmonary arrest due to septic shock. Despite constant cardiopulmonary resuscitation (CPR), the return of spontaneous circulation was not confirmed, and veno-arterial extracorporeal membrane oxygenation (ECMO) was introduced (Picture A, arrow). After resuscitation, she was weaned off of ECMO on day 4. Echocardiography revealed a massive thrombus in the shape of a catheter in the inferior vena cava (IVC) near the right atrium after the removal of venous cannulation from the right femoral vein (Picture B, C, arrows).
Picture.
There are many complications associated with ECMO usage, including bleeding and thrombosis (1); however, IVC thrombosis is rare. Risk factors for thrombosis include severe disease, sedation, frequent blood transfusion, and blood exposure to the ECMO circuit (2). Anticoagulation therapy should generally be administered in the management of ECMO. However, our patient had pulmonary contusion with bloody phlegm due to chest compressions performed during CPR, so anticoagulation agents had to be avoided until ECMO removal. After detecting IVC thrombosis, intravenous heparin sodium was administered immediately, and the activated partial thromboplastin time (APTT) was maintained at 50-70 seconds to treat this massive thrombus. Due to intravenous heparin sodium, IVC thrombosis gradually decreased on follow-up echocardiography. Anticoagulation therapy was terminated on day 16 (ECMO removal), and the disappearance of the thrombus was confirmed. Her general condition gradually improved without pulmonary embolism or other thrombus complications, and she was transferred to her family doctor for rehabilitation on day 76.
In the present case, coagulopathy due to sepsis, pulmonary contusion, and blood transfusion during resuscitation without anticoagulation therapy may have contributed to the development of this IVC thrombosis. Although IVC thrombosis is a rare complication of ECMO-related thrombosis, pulmonary embolism caused by IVC thrombus shedding may be life-threatening.
The authors state that they have no Conflict of Interest (COI).
References
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