Management of lower extremity venous congestion during peripheral venoarterial extracorporeal membrane oxygenation

During venoarterial extracorporeal membrane oxygenation, right lower extremity congestion occurred due to the insertion of a drain cannula. We effectively managed leg congestion by inserting an additional catheter into the ipsilateral superficial femoral vein. Extracorporeal membrane oxygenation (ECMO) is an important supportive method for circulatory or respiratory shock.1-3 Physicians usually insert cannulas into the common femoral artery and vein, particularly during venoarterial ECMO (V-A ECMO) support. Distal perfusion of the superficial femoral artery is predominantly conducted to prevent lower extremity hypoperfusion. Venous drain cannula insertion into the femoral vein decreases lower extremity venous circulation to the heart, which may occasionally cause lower extremity congestion.4 However, lower extremity congestion is not considered as important as lower limb arterial hypoperfusion, and only a few cases of lower extremity congestion during V-A ECMO have been reported. In this report, we effectively resolved this issue by inserting an additional 8-Fr drain sheath cannula into the superficial femoral vein. A 76-year-old female patient was admitted to our hospital due to acute heart failure. She has been on outpatient care for idiopathic dilated cardiomyopathy and underwent implantable cardioverter defibrillator insertion 2 years ago after ventricular fibrillation with successful resuscitation. Upon admission, transthoracic echocardiography revealed an ejection fraction of 16% and a left ventricular diastolic dimension of 8.20 cm, with moderate-to-severe-graded (graded III–IV) mitral regurgitation (MR) and moderate-graded (graded II) aortic regurgitation (AR). The right ventricle exhibited mildly and globally decreased systolic function, with a 30% fraction area change. The right atrial volume and volume index were 77.8 mL and 57.21 mL/m2, respectively. Heart failure continued to aggravate with metabolic acidosis despite inotropes and diuretic management. Consequently, we decided to initiate V-A ECMO support. However, the risk of developing left heart and pulmonary congestion was high after V-A ECMO support initiation because this patient had graded III–IV MR and graded II AR. Therefore, we planned to place a venous drain cannula in the left and right atrium through interatrial septostomy for left atrial venting. We applied V-A ECMO support (Permanent Life Support, Getinge, Gothenburg, Sweden). Ultrasonography revealed femoral artery and vein diameters of 9 and 14 mm on the right and 9 and 12 mm on the left side, respectively. The 24-Fr and 17-Fr (HLS Cannula, Getinge, Gothenburg, Sweden) drain and return cannula were inserted into the right common femoral vein and left common femoral artery, respectively. We positioned a venous drain cannula in the left and right atria through interatrial septostomy. The flow of ECMO was 2300 mL/min after V-A ECMO support initiation. We inserted an additional 17-Fr venous drain cannula into the right internal jugular vein due to insufficient venous drainage (Figure 1), and the flow of V-A ECMO was increased to 3600 mL/min. A 7-Fr distal perfusion cannula was also inserted into the left superficial femoral artery. The patient's metabolic acidosis improved after V-A ECMO support initiation. However, cyanosis and swelling occurred in the right leg, where a return cannula was inserted (Figure 2A) the day after the procedure. The patient complained of mild right leg pain, and the leg was cold and pale. The patient reported no paresthesia or paralysis, and the arterial pulse of the right dorsalis pedis was intact. Despite additional treatments, including intravenous nitroglycerin and alprostadil, warm air, and intermittent pneumatic compression, right lower limb congestion with cyanosis was not improved. The arterial blood gas analysis revealed mild metabolic acidosis, including pH of 7.3, lactate of 4.5 mmol/L, PCO2 of 32.3 mm Hg, HCO3 of 20.0 mEq/L, base excess of −5.2 mEq/L, PO2 of 194 mm Hg, and SaO2 of 98.5%. Doppler ultrasonography revealed no blood flow in the popliteal vein (Figure 3A), and sonography detected a dilated and noncompressible superficial femoral vein. We diagnosed the patient with lower extremity venous congestion and resulting metabolic acidosis. An 8-Fr sheath cannula (Prelude Sheath Introducers, Merit Medical Systems, Utah, USA), a non-wire-reinforced sheath, was additionally inserted into the superficial femoral vein (Figures 1 and 4) to drain lower extremity venous blood. The patient's cyanosis and swelling improved after inserting the drain sheath cannula into the superficial femoral vein (Figure 2B), and blood flow in the popliteal vein was observed on Doppler ultrasonography (Figure 3B). The target for activated partial thromboplastin time (aPTT) of heparinization was 1.5–2.0 times the patient's baseline aPTT since the venous congestion in the lower extremity had been resolved. In South Korea, age over 70 is a relative contraindication depending on associated comorbidities and the patient's condition.5 Although the patient was 76 years old, she had no other comorbidities, and her other organ functions were good. For this reason, we enlisted this patient on the heart transplantation waiting list. The patient underwent a heart transplant 5 days after V-A ECMO support initiation and the V-A ECMO cannulas were successfully removed after heart transplantation. She was discharged from the hospital without any complications, and the latest vascular sonography revealed no arterial and venous thrombosis in both lower extremities. Lower extremity congestion after a venous drain cannula insertion into the common femoral vein during ECMO support is rare, especially with severe congestion. However, deep vein thrombosis (DVT) in the limb may develop if severe lower extremity congestion is left untreated, and metabolic acidosis may occur, as in this case. Systemic anticoagulation is used in ECMO support, but it cannot completely prevent DVT.3 The risk of DVT increases even further, particularly in cases similar to this patient, wherein the lower extremity venous flow is completely obstructed due to the venous drain cannula (Figure 3). Venous drainage to alleviate the congestion is recommended in this situation.4 However, only a few studies report effective lower extremity venous drainage methods. Le Guyader et al.4 recommended inserting an 11-Fr additional drain cannula into the superficial femoral vein to facilitate lower extremity venous drainage. In this case, we inserted an 8-Fr sheath cannula into the superficial femoral vein to relieve lower extremity congestion. The 8-Fr sheath cannula provided sufficient drainage to alleviate the lower extremity congestion, and hemostasis was successfully achieved with compression alone, without any complications, after the sheath cannula removal. In conclusion, cannulation and drainage of the superficial femoral vein alone with an 8-Fr sheath cannula were sufficient to resolve severe lower extremity congestion caused by common femoral vein cannulation during ECMO support. The release of lower extremity venous congestion effectively improved the patient's lower leg congestion and metabolic acidosis and prevented DVT. KS was the first author and a major contributor to writing the manuscript. JHY and HJL made critical revisions. Not applicable. None. The authors declare that they have no competing interest. The Institutional Review Board of the Dongsan Medical Center approved the study (IRB File No. 2024-05-059, May 28, 2024). The requirement for informed consent was waived due to the retrospective nature of the study.