52: When ECMO Goes AWRY – Limb to Life Threatening Complications Post De-Cannulation in VA-ECMO

Background: Peripartum cardiomyopathy (PPCM) occurs in approximately 1 in 1400 pregnancies in India. Catastrophic presentations may necessitate mechanical circulatory support such as intra-aortic balloon pump (IABP), Impella, or veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Case Description: A 26-year-old primigravida at 32 weeks of gestation presented with worsening dyspnea for one week. She was diagnosed with preeclampsia and peripartum cardiomyopathy with severe left ventricular dysfunction. Following an emergency cesarean section, she developed cardiogenic shock with severe metabolic acidosis and was initiated on peripheral VA-ECMO. The patient was successfully weaned off ECMO and decannulated on day four while on IABP support. Six hours post-decannulation, she developed hypovolemic shock secondary to intra-abdominal hemorrhage. Ultrasonography revealed a left external iliac artery pseudoaneurysm with intra- and extraperitoneal hematoma. Angiographic stenting was attempted but unsuccessful, necessitating open surgical repair with femoro-femoral bypass. She required massive blood transfusion and developed multiple complications, including transfusion-related acute lung injury (TRALI), disseminated intravascular coagulation (DIC), and acute lung injury (ALI). Her clinical course was further complicated by left above-knee amputation, tracheostomy, and prolonged hospital stay. With rigorous multidisciplinary care, she was discharged in a stable condition after 45 days of hospitalization. Conclusion: Nearly 60% of all peripartum ECMO cases are due to cardiovascular causes, of which 17% result from PPCM. Vascular complications occur in 10–30% of ECMO cases and may be early or late. Open surgical cannulation is associated with fewer late vascular complications compared to percutaneous techniques (15% vs. 3%). This case highlights the importance of early recognition, meticulous vascular management, and multidisciplinary collaboration in achieving favorable outcomes in complex peripartum ECMO cases.