The Worst Nightmare of Percutaneous Extracorporeal Membrane Oxygenation
Presenter
Dr. Cze Ci Chan, MD, Linkou Chang Gung Memorial Hospital, Taoyuan, Taoyuan, Taiwan
Dr. Cze Ci Chan, MD, Linkou Chang Gung Memorial Hospital, Taoyuan, Taoyuan, Taiwan and Chien- Te Eric Ho, Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taoyuan, Taiwan
Title
The Worst Nightmare of Percutaneous Extracorporeal Membrane Oxygenation
Introduction
This is a case of coronary artery disease (CAD), triple-vessel-disease, complicated with acute thrombosis of left coronary arteries during percutaneous coronary intervention (PCI). The patient collapsed due to severely compromised left coronary artery (LCA) flow. Extracorporeal cardiopulmonary resuscitation (ECPR) was started and percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO) was inserted without delay. Unfortunately, it was complicated with Stanford Type A Aortic Dissection which was later confirmed by computed tomography angiography (CTA).
Clinical Case
A 78-year-old Taiwanese female with type 2 diabetes mellitus and hypertension presented to a local hospital with angina and dyspnea. She was diagnosed with non-ST elevation acute coronary syndrome and coronary angiography (CAG) showed CAD, triple-vessel-disease by coronary angiography. She was then transferred to our hospital after a failed percutaneous coronary intervention there. Due to her old age, her family refused coronary artery bypass grafting (CABG) so we tried PCI again. The left anterior descending coronary artery (LAD) was wired across with Asahi Gaia First guide wire in Asahi Corsair Pro microcatheter. However, 1.0mm coronary balloon was uncrossable, and the guide wire and microcatheter were entrapped in LAD. After successful retrieving of the both, bradycardia with hypotension developed and angiography showed TIMI-1 flow with thrombus formation at LCA. Balloon angioplasty with 2.0mm balloon at proximal left main, ramus and left circumflex was performed immediately. Unfortunately, pulseless electrical activity (PEA) and ventricular arrhythmia were noted, so we started ECPR and percutaneous VA-ECMO was implanted with an 18-French femoral venous cannula in the left femoral vein and a 15-French arterial perfusion cannula in the femoral artery. However, blood flow decreased dramatically from 2.0L/min to 0.9L/min and could not be improved by fluid challenge nor vasopressors. Contrast injection was performed and revealed type A aortic dissection. Cardiovascular surgeons were consulted immediately, and CTA showed Stanford Type A aortic dissection. Emergent operation of replacement of ascending aorta and CABG were performed. Profound cardiogenic shock was still noted and altered mental status was noted the next day. Brain CT showed acute right parietooccipital subdural hematoma. The patient died eventually.
Discussion
This is a case of a life-threatening complication of Stanford Type A Aortic Dissection caused by VA-ECMO. It is assumed that the aortic dissection occurred during cannulation of the femoral artery causing retrograde dissection from the common iliac artery to ascending aorta. Peripheral VA-ECMO has been preferred to central VA-ECMO because it is less invasive, fast and simple to establish, and no need for surgical exposure of the heart and great vessels. However, peripheral cannulation can also be quite morbid, especially there is a significant risk of ischemic vascular complications. Iatrogenic aortic dissection (IAD) is an uncommon but serious complication of cardiac catheterization and cardiac surgical procedures. Despite aggressive and timely surgical treatment, IAD is associated with a high risk of perioperative morbidity and mortality. Caution taken in the placement of the aortic cannula of VA-ECMO may prevent complications that may be fatal.