Retrograde cranial malposition of central line guidewires in a Veno-Arterial-Venous ECMO patient: A case report

Extracorporeal membrane oxygenation (ECMO) has become increasingly utilized both electively and emergently to provide cardiac and/or respiratory support. Central venous catheter (CVC) access is essential for hemodynamic monitoring, administering critical medications, and enabling rapid interventions, such as massive transfusions during surgery. Proper CVC position is essential for its appropriate function and to avoid complications. However, malposition occurs in up to 6.7 % of cases, increasing the risks of catheter dysfunction and mortality-morbility. In our case, a patient with a massive liver metastasis extending into the right chest, causing diaphragm elevation and leftward heart shift, was scheduled for complex surgery with pre-induction Veno-Arterial-Venous ECMO (VAV-ECMO) cannulation in the superior vena cava via right internal jugular (IJ) vein. This presented unique challenges for CVC placement via left IJ vein. When guidewires were not visualized by intraoperative transesophageal echocardiography (TEE), X-ray was used to identify cranial retrograde malposition of guidewires. The guidewires of CVC were subsequently repositioned under TEE and X-ray guidance. This case report highlights the value of imaging guidance in achieving proper CVC placement in VAV-ECMO patient with complex anatomical cases.