Access without available arterial access options in an ECMO Patient: A Case Report
Presenter
Samuel Moore, D.O., Texas Health Presbyterian Hospital Dallas, Dallas, TX
James B. Park, M.D., Samuel Moore, D.O., Bryan Hoang, M.D. and Stephanie Koepke, MSN, ACNS-BC, Texas Health Presbyterian Hospital Dallas, Dallas, TX
Title:
Access without available arterial options in an ECMO patient: A Case Report
Introduction:
Patient is a 68 yo female with a past medical history of adrenal insufficiency, hypertension, hyperlipidemia, hypothyroidism, COPD, DM and morbid obesity who presented with a chief complaint of chest pain for 2 days prior to presentation. The patient at the referring center was found to have troponin elevation to 27,000 and was immediately taken to the cathlab where she was found to have 99% occlusion of the left main artery and an open RCA. An impella CP was then placed and PTCA of the left main. This did not resolve the lesion of the left main because it was highly calcified but did achieve TIMI 3 flow to the Circumflex and the patient was then transferred to our facility for higher level of care and Cardiogenic Shock.
Clinical Case:
After the transfer,the Shock team assessed the patient who by this time had a lactate level of 9.7 and was in profound cardiogenic shock. The team felt that the patient needed mechanical and circulatory support and was placed on ECMO with the arterial and venous cannulas being placed through the left common femoral artery and vein. We also noted that the patient's right groin had bleeding issues and a hematoma and so the CT surgical team tried to upsize the impella to the 5.5 from the right subclavian artery but due to the caliber of the vessel and the tortuosity, we were only able to place a CP. However, we were able to remove the CP from the right groin and the patient had repair of the right common femoral artery by vascular surgery. After stabilization of the patient, the team felt that the patient needed revascularization of the left main. We needed to contemplate high risk PCI, however, an arterial access was problematic given the impella in the right subclavian artery and her right radial was so poor even an art line was difficult to place and her left radial was poor as well. Her right groin had just undergone vascular surgery repair and the left common femoral artery had the VA arterial cannula. After much thought and some review of a reported case, we decided to access the arterial cannula of the ECMO circuit. Using the micro-puncture needle, I was able to place a 6F sheath. Complex coronary intervention was done successfully. After the PCI, we were able to clamp above the connector tubing and below the insertion site of the sheath then remove the sheath, excise out that segment and reconnect the cannula to the circuit without compromise to the patient. The patient was then transferred back to the CVICU for further medical management and shock management.
Discussion:
Given the complexity of the patients we receive as a shock HUB center the need arises for some of these patients to have complex and high risk coronary revascularization. This case highlights a potential safe access points for some of these patients