Title
A SERIES OF UNFORTUNATE EVENTS: A CASE OF RECURRENT LAD THROMBOSIS COMPLICATED BY CARDIOGENIC SHOCK MANAGED WITH PERCUTANEOUS LEFT AXILLARY VA-ECMO CANNULATION Introduction
Traditionally, cannulation for ECMO is performed using femoral vessels. However, in certain situations a femoral approach may not be feasible. We present a complicated case involving a completely thrombosed LAD, coronary artery bypass grafting occlusion, and cardiogenic shock approached with a left axillary cannulation for venoarterial ECMO.
Clinical Case
A 35-year-old obese male presented with substernal chest pain and anterior ischemic ECG changes. Echocardiogram showed an ejection fraction of 35-40%. Left heart catheterization demonstrated 100% LAD occlusion and severe aneurysmal/ectatic vessels. Percutaneous angioplasty followed by rheolytic thrombectomy reestablished flow. Intravascular ultrasound demonstrated 8-10 mm average luminal diameter. Due to significant thrombotic burden, an intra-aortic balloon pump and combination intravenous P2y12 inhibitor and Gp2b3a inhibitors were instituted. Coronary angiogram after 24 hours demonstrated completely occluded LAD. Heart team decision was to proceed with coronary bypass grafting with LIMA to LAD. Six hours after CABG, the patient went into fulminant cardiogenic shock. Repeat angiogram demonstrated occluded LIMA and LAD. The shock team concluded that VA-ECMO and emergency PCI should be attempted. Due to poor body habitus, risk of bleed, and severely narrowed vasculature, a percutaneous, preclosed 19Fr left axillary artery with 25Fr femoral venous return approach was chosen. We then proceeded with repeat coronary intervention under IVUS guidance. Ultimately, after using a combination of repeated rheolytic/mechanical thrombectomy and intracoronary lytic therapy we were able to reconstitute the LAD. Using IVUS, we then placed overlapping drug-eluting stents from distal to mid-proximal vessel. On the final post-dilation balloon deflation, the patient’s blood pressure dropped precipitously, ECMO circuit lost flow, and the chest tubes started draining blood. He developed cardiac arrest, with repeat coronary angiography demonstrating avulsion of the LIMA from the LAD. Immediate attempt at placing a covered coronary stent was performed but did not seal due to size mismatch, and a proximal 7.0 mm balloon was inflated and maintained hemostasis. He then underwent repeat cardiac surgery with pericardial patch repair. He was managed on VA-ECMO for 11 days, and then percutaneously explanted with EF recovery to 50-55%. Patient developed a brachial plexopathy due to persistently abducted arm to prevent cannula kinking. He continues to do well at 6 months follow-up with rehabilitation.
Discussion
Recurrent LAD thrombosis in the setting of aneurysmal disease is a rare event that may result in shock. Percutaneous axillary VA-ECMO is an attractive option for the management of profound cardiogenic shock in patients whom femoral arterial access is clinically not feasible. Knowledge of peripheral access and closure techniques, and prevention/identification of brachial plexopathy should be a part of the skillset of shock interventionalists.