Managing High-Risk Liver Transplantation: A Case of Budd-Chiari Syndrome With Preemptive Venovenous Extracorporeal Membrane Oxygenation (ECMO)

We report the use of preemptive dual-cannula venovenous extracorporeal membrane oxygenation (VV-ECMO) during orthotopic liver transplantation in a 21-year-old patient with Budd-Chiari syndrome (BCS) with diffuse hepatic vein thrombosis and inferior vena cava (IVC) narrowing. Progressive liver dysfunction and unsuccessful transjugular intervention led to urgent transplantation. Given the anticipated intraoperative cardiopulmonary instability and surgical complexity, VV-ECMO was initiated before IVC clamping. Classic hepatectomy with portocaval shunt was performed. Portal flow was restored without post-reperfusion syndrome. Protamine was not administered, and no ECMO-related complications occurred. This case highlights the role of preemptive ECMO as a safe strategy in high-risk liver transplantation because of the anticipated severe hemodynamic instability during hepatectomy and IVC clamping due to BCS with extensive hepatic vein thrombosis and IVC stenosis, providing continuous cardiopulmonary support.