THORACIC CENTRAL VEIN OCCLUSION CAUSING LUNG COLLAPSE IN A PATIENT ON VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION

Abstract

SESSION TITLE: Clinical Conundrums in ECMO SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/20/2019 1:00 PM - 2:00 PM INTRODUCTION: Thoracic central vein occlusion (TCVO) is a feared complication in hemodialysis (HD) patients. Superior vena cava (SVC) obstruction impeding thoracic venous flow to the right atrium (RA) results in upper body and facial edema. We describe a case of TCVO in a patient on veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) associated with azygous vein (AV) distension causing right mainstem (RMS) bronchus compression and lung collapse. CASE PRESENTATION: A 56-year-old woman with Hodgkin’s lymphoma was admitted with acute respiratory distress syndrome and herpes simplex pneumonia. Despite lung protective ventilation and paralysis, she remained hypoxemic. She progressed to refractory shock in the setting of severely reduced cardiac function and sepsis. VA-ECMO using a femoral configuration was initiated. Two days after ECMO cannulation, she developed arm and facial edema as well as collapse of the right lung (Figure 1). A bronchoscopy showed RMS bronchus occlusion by an extrinsic structure. Endobronchial ultrasound showed a vascular structure at the carina obstructing the RMS consistent with a severely distended AV. The ECMO configuration was changed to facilitate dual caval drainage. The SVC was drained via a 14-French (Fr) cannula, the inferior vena cava (IVC) was drained via a 25-Fr cannula, and oxygenated blood was returned to the patient via femoral artery cannulation. The addition of the dedicated SVC drainage cannula resulted in improvement in edema and AV distention, and thus extrinsic compression of the RMS resolved (Figure 2). The patient improved and was weaned off ECMO. Later, a stent was placed in the SVC with durable resolution of the obstruction. DISCUSSION: A common VA-ECMO technique is insertion of a venous cannula in the IVC or RA for drainage and an arterial cannula in the femoral artery for return of pressurized oxygenated blood to the patient. In our patient, femoral access in the setting of underlying SVC obstruction led to inadequate drainage of the upper half of the body causing venous hypertension with upper extremity, torso and face edema, similar to TCVO described in HD patients. AV distension led to RMS bronchus compression and caused right lung collapse. This complication has not previously been described. By changing the ECMO configuration to dual caval drainage, the SVC obstruction was bypassed and drainage of the upper half of the body could be achieved. CONCLUSIONS: ECMO is a life-saving therapy in patients with refractory cardiorespiratory failure that can be associated with severe complications. Consideration of different cannula configurations depending on the patient’s anatomy is important since placement of these catheters is associated with morbidity (1). SVC obstruction causing inadequate drainage of the upper half of the body in patients on VA-ECMO is rarely seen, and resulting AV distension leading to RMS bronchus compression is rarer still. Reference #1: 1. Zangrillo A, Landoni G, et al. A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. Crit Care Resusc 2013;15:172-8. DISCLOSURES: No relevant relationships by Seema Amin, source=Web Response No relevant relationships by Haval Chweich, source=Web Response No relevant relationships by Erik Garpestad, source=Web Response Consultant relationship with Abiomed Please note: $1001 - $5000 Added 03/14/2019 by John Reich, source=Web Response, value=Consulting fee