VV-ECMO cannulation-related right brachiocephalic vein injury associated with pleural empyema

Introduction The benefits of veno-venous extracorporeal membrane oxygenation (VV-ECMO) for patients with acute respiratory distress syndrome (ARDS) are well established. However, cannulation-related vascular complications, while rare, can be life-threatening. Case Report An 82-year-old man with ARDS caused by pleural empyema and lung abscess required VV-ECMO for worsening acidemia and hypoxemia. During internal jugular vein cannulation, a purulent effusion abruptly emerged from the outflow catheter. CT revealed catheter perforation of the brachiocephalic vein with fistulization into the pleural empyema. ECMO support was re-established using an alternative configuration. Following surgical repair, the patient gradually recovered to ambulatory discharge. Discussion Catheter penetration into a pleural empyema in the absence of congenital anomalies is extremely rare. Here, inflammation-related vascular fragility likely contributed. This highlights the importance of considering intrathoracic pathology when determining ECMO configuration. Conclusion Pleural empyema may predispose patients to vascular complications associated with VV-ECMO. A tailored ECMO configuration is essential.