Accidental Lumbar Vein Cannulation During Emergent Veno-Venous Extracorporeal Membrane Oxygenation Initiation: Case Report

A 31-year-old woman at 41 weeks gestation presented after a home-delivery attempt, resulting in an intrauterine fetal demise. A cesarean section revealed purulent amniotic fluid. The patient had a hypoxic cardiopulmonary arrest due to aspiration and fluid overload from resuscitation. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) via femorofemoral approach was initiated to treat refractory hypoxemia. Because of the emergent nature, a cardiac ultrasound probe was not readily available to verify guidewire placement. However, there was no resistance during placement; adequate flows were obtained. She was transferred to our tertiary ECMO center. A computed tomographic angiography to investigate her cardiac arrest revealed the 25-Fr drainage cannula exiting the inferior vena cava (IVC) into a lumbar vein (Figures 1–3). Because the proximal drainage port was low-lying, the cannula was retracted by 3 cm. The ECMO run was uneventful, without chattering, low flows, or low-pressure alarms. The patient was discharged home without neurological deficits.Figure 1.: Computed tomography images of the Abdomen and Pelvis in soft tissue format. A: Coronal. B: Sagittal cuts. Drainage cannula exiting the inferior vena cava into a lumbar vein at the level of the L2 vertebral body with the most distal tip at the L1 with no surrounding hematoma.Figure 2.: Computed tomography images of the Abdomen and Pelvis in maximum intensity projection format. A: Coronal. B: Sagittal cuts. 25-Fr multi-stage drainage cannula in the right common femoral vein and a 23-Fr single-stage outflow cannula in the left common femoral vein were used.Figure 3.: Computed tomography images of the Abdomen and Pelvis in 3D-rendered format. A: Coronal. B: Sagittal cuts. Before dilation and placement of extracorporeal membrane oxygenation cannulas, the guidewire should ideally be confirmed to be in the inferior vena cava, entering the right atrium during the femoral approach and not entering the hepatic vein during the internal jugular or subclavian method. 3D, three-dimensional.Cannulation under fluoroscopic guidance provides precise and safe positioning.1 Cannulation under real-time ultrasound guidance can also be successfully achieved with low complication rates. Reports of ECMO cannula malposition include a retrograde hepatic venous flow from a bicaval cannula and drainage cannula into an accessory hepatic vein.2,3 Gocze et al.4 reported a dialysis catheter in the anterior lumbar vein. Complications include retroperitoneal hematomas and devastating neurological symptoms, as the catheter tip can stray into the subarachnoid or epidural space. After 20 weeks of gestation, a gravid uterus compresses the IVC. Our patient’s compressed IVC and hypovolemic state may have caused the non-J guidewire to take a downward trajectory into the lumbar vein. We recommend implementing a 15°–30° left lateral tilt, as described by Ngatchou et al.,5 which can partially release the aortocaval compression seen in late pregnancy, allowing an easier and safer cannulae advancement. Real-time ultrasound or fluoroscopic guidance during cannulation mitigates potential complications. Acknowledgments The authors thank Michelle Gehring, PhD, ELS and Jessica Moody, PhD, ELS for their editorial and submission support.