28: Inferior Vena Cava Perforation During ECMO Cannulation: A case report

Background: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is an established rescue therapy for refractory respiratory failure. Despite advances in cannulation techniques and imaging guidance, mechanical complications during insertion have been reported. Among these, inferior vena cava (IVC) perforation is an exceedingly rare but potentially fatal event that may occur during guidewire or cannula advancement. Case: A 30-year-old female, known asthmatic on bronchodilator therapy. presented to the emergency department with acute severe asthma refractory to standard management, complicated by pneumomediastinum and persistently high airway pressures, and was subsequently initiated on VV ECMO on day 3 of ICU admission. Within hours of ECMO initiation, frequent drops in ECMO flow were observed, transiently responsive to fluid boluses and RPM adjustments. CT abdomen revealed a sealed perforation of the left iliac vein with a small retroperitoneal hematoma and partial malposition of the drainage cannula out of the IVC. Given the risk of worsening perforation and potential “no-flow” scenarios, the decision was made to proceed with IVC repair under ongoing ECMO support. VV ECMO was converted to Veno-Arterial (VA) configuration by inserting a 20 Fr left femoral arterial cannula. Under fluoroscopic and venographic guidance, two covered stents were deployed to seal the IVC perforation. A balloon occlusion was performed in the left common iliac vein during cannula removal to minimize bleeding. Once venography confirmed no leak, the femoral venous drainage cannula was repositioned under fluoroscopy, and ECMO was reverted to VV configuration.The patient was successfully weaned on day 7 and made a favourable recovery. Conclusion: ECMO cannulation is associated with a risk of vascular injuries. Early anticipation, prompt diagnosis, and a multidisciplinary team approach are vital for the identification and successful management of such complications, ensuring favourable patient outcomes.