Echocardiographic Image of Extracorporeal Membrane Oxygenation Cannula-Associated Inferior Vena Cava Thrombosis and Filter Implantation

A 27-year-old man sought treatment for fatigue that had lasted for 30 h, chest tightness, and shortness of breath that had lasted for 6 h, accompanied by hypotension. He was admitted to our ED. The patient’s BP remained low despite large doses of positive inotropic drugs and vasoactive drugs. He was found to have an acute course of disease, with prodromal symptoms of the upper respiratory tract accompanied by hemodynamic disturbances (BP, 71/52 mm Hg). Bedside ultrasound showed diffuse left ventricular wall motion weakening (ejection fraction, < 30%), and blood work showed severe myocardial injury (troponin I, 47.82 μg/L). The diagnosis was fulminant myocarditis. Bedside ultrasound-guided femoral venoarterial extracorporeal membrane oxygenation (ECMO) was performed. The right femoral artery was cannulated for autotransfusion (16 F), and the left femoral vein was cannulated for drainage (21 F). During the venoarterial ECMO support period, echocardiography showed cloud-like changes in the inferior vena cava IVC; however, no thrombus was found in the cardiac cavity. Systemic heparin anticoagulation therapy was administered, maintaining activated partial thromboplastin time at 1.5 to 2 times, and the patient’s clinical condition improved. However, on the third day of venoarterial ECMO, transthoracic echocardiography located a thrombosis around the IVC drainage tube (Fig 1A). Venoarterial ECMO was discontinued after 7 d, and transthoracic echocardiography confirmed that a tubular thrombus was located at the cannulation site in the IVC for drainage after withdrawing the ECMO cannula (Fig 1B, 1C, Video 1). Surprisingly, the tubular thrombus was at risk of detachment at any time and was 4 cm away from the right atrial orifice (Fig 1D). However, a pulmonary embolism (PE) did not develop. Question: After reviewing the clinical information and echocardiographic images, what would you recommend as the next step? Answer: Under digital subtraction angiography contrast, the IVC filter was implanted through the femoral vein. Then, the filter was anchored at a position 3.5 cm away from the right atrial orifice (Fig 2A, 2B, Video 2), and the thrombus was attached tightly to the blood vessel wall so as to fix the thrombus and prevent further detachment. After 3 weeks of treatment with the IVC filter combined with anticoagulation therapy, the IVC filter was removed successfully, and repeated transthoracic echocardiography evaluation showed that no residual thrombotic material was present (Fig 2C, 2D, Video 3). No symptoms or clinical signs of IVC syndrome (such as edema of the lower limbs) or PE (such as dyspnea) were present. ECMO is a type of extracorporeal life support technology that is used to replace patient cardiopulmonary function partially or completely such that complete rest can be achieved, providing time for the diagnosis and treatment of the primary disease.1Lorusso R. Shekar K. MacLaren G. et al.ELSO interim guidelines for venoarterial extracorporeal membrane oxygenation in adult cardiac patients.ASAIO J. 2021; 67: 827-844Crossref PubMed Scopus (83) Google Scholar Venoarterial ECMO can provide effective cardiopulmonary bypass support for patients with cardiogenic shock, can promote the recovery of cardiopulmonary function, and effectively can prevent organ failure caused by hypoperfusion, thus significantly reducing mortality. Although ECMO technology has been improved greatly, bleeding and thrombosis remain its primary complications. These complications and the related mortality and disability rates currently present a great challenge to the clinical application of venoarterial ECMO. Echocardiography has been used increasingly in the management of critically ill patients because of its noninvasiveness, instantaneity, convenience, and the feasibility of repeated and bedside monitoring. At present, echocardiography is an important examination method to detect and manage complications in patients undergoing venoarterial ECMO and plays an important role at three stages: assessment of the condition before cannulation, guidance during cannulation, and management after the procedure. Echocardiography and ultrasonography also are the first choices for IVC assessment.2Chen Y.L. Chen H.S. Liu X.Y. et al.IVC thrombosis during extracorporeal membrane oxygenation: a case report and review of the literature.J Med Case Rep. 2021; 15: 529Crossref PubMed Scopus (4) Google Scholar During venoarterial ECMO treatment, if the left ventricular output cannot be maintained, the blood flow in the cardiac chamber may be slow and stagnant because of the reverse blood flow in the ascending aorta, which may lead to thrombosis in the cardiac chamber. Cloud-like echoes can be observed in patients with cardiogenic shock, manifested as slowing of the blood circulation in the heart cavity and blood vessels. Despite supportive treatment for cardiopulmonary bypass support, the significant cloud-like echoes remain and are not weakened or eliminated until the primary disease improves. Cloud-like echo changes may not necessarily progress to thrombosis, but the prethrombotic state can predict thrombosis. In this patient, we detected thrombosis on the cannula of ECMO venous cannulation by echocardiography on the third day of ECMO treatment. Fortunately, wrapping by the thrombus did not cause adverse effects such as poor venous blood collection for ECMO. After withdrawal of ECMO, echocardiography further revealed a thrombus in the IVC that was attached to the blood vessel wall, and detachment at any time was a risk, accompanied by the risk of a massive PE. Previous reports have shown that cannula-associated DVT during ECMO support is rare, especially after venoarterial ECMO.3Cui Y.C. Yang F. Hou X.T. Echocardiographic image of a cannula in the IVC after decannulation of venoarterial extracorporeal membrane oxygenation.Chest. 2021; 160: e527-e530Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The risk factors of cannula-associated DVT include the catheter being a foreign body, the large diameter of the cannula, cannula site, insufficient anticoagulation, high levels of fibrin and factor VIII, heparin resistance, and platelet activation. At present, unfractionated heparin remains the first-choice anticoagulant in almost all ECMO centers around the world. Laboratory monitoring methods to guide heparin dosage mainly include activated clotting time, activated partial thromboplastin time, antithrombin III activity, anti-factor Xa activity, and thromboelastography; each method has its advantages and limitations. This patient continued to receive heparin for anticoagulation. Activated partial thromboplastin time was used to monitor its anticoagulation effect, and it was determined that it had a poor effect in reversing thrombosis. At present, the optimal treatment method for IVC thrombosis remains unclear, and alternative treatments include anticoagulation, thrombolysis, IVC filter placement, and surgical embolectomy. Because of differences among patients, the treatment methods reported by various ECMO centers are different. Research shows that from 1997 through 2021, 13 cases of IVC thrombosis related to ECMO cannulation were reported, including eight cases in patients who underwent Vein-Vein-ECMO, five patients undergoing venoarterial ECMO, 11 patients treated with anticoagulation therapy, one patient treated with thrombectomy, and one patient not treated. Among these, one patient had a PE, 11 survived, and two died.3Cui Y.C. Yang F. Hou X.T. Echocardiographic image of a cannula in the IVC after decannulation of venoarterial extracorporeal membrane oxygenation.Chest. 2021; 160: e527-e530Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,4Hussey P.T. von Mering G. Nanda N.C. et al.Echocardiography for extracorporeal membrane oxygenation.Echocardiography. 2022; 39: 339-370Crossref PubMed Scopus (3) Google Scholar Because the present patient was at risk of thrombus detachment at any time while receiving anticoagulation, preventive placement of an IVC filter was considered a good choice. During the operation, the Seldinger technique was used to puncture the left femoral vein and IVC. Angiography was performed to define further the location and extent of the thrombus. The filter was released approximately 1 cm superior to the thrombus and approximately 3 cm from the right atrial opening. Heparin and rivaroxaban were administered as part of the postoperative anticoagulation therapy, and heparin was discontinued after 3 days of rivaroxaban treatment. The filter position and status of the thrombus were monitored regularly by echocardiography. To our knowledge, this is also the first reported case of an ECMO cannula-associated thrombus implanted with an IVC filter. In patients with indwelling retrievable or convertible IVC filters whose risk of PE has been mitigated or who are no longer at risk of PE, the guidelines suggest that filters be removed or converted routinely unless the risks outweigh the benefits.5Kaufman J.A. Barnes G.D. Chaer R.A. et al.Society of Interventional Radiology Clinical Practice Guideline for inferior vena cava filters in the treatment of patients with venous thromboembolic disease: developed in collaboration with the American College of Cardiology, American College of Chest Physicians, American College of Surgeons Committee on Trauma, American Heart Association.J Vasc Interv Radiol. 2020; 31: 1529-1544Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar As soon as the patient is no longer at risk of PE, the window for the removal of the retrievable IVC filter is 4 to 7 weeks after placement. Of course, some experts have suggested that removing the retrievable IVC filter as early as possible after mitigating the risk of PE is safe.6Morales J.P. Li X. Irony T.Z. et al.Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism.J Vasc Surg Venous Lymphat Disord. 2013; 1: 376-384Abstract Full Text Full Text PDF PubMed Google Scholar The present patient’s vital signs at week 3 were stable with no specific reports of discomfort, he was walking freely, his D-dimer levels had returned to normal, and repeat echocardiography examination indicated that the IVC filter was well positioned with a reduced or absent thrombus. Thus, it was decided that the IVC filter be removed at week 3. After the operation, echocardiography examination showed no significant thrombus residue in the IVC. Rivaroxaban anticoagulation therapy was continued for 1 month after filter removal. To conclude, echocardiography is extremely important and advantageous for dynamic monitoring of ECMO-related catheter thrombosis. Echocardiography also provides imaging evidence for further treatment decisions, monitoring of filter location, thrombus status, and follow-up after discharge. 1.Cannula-associated DVT is a rare complication after venoarterial ECMO weaning, and it is not clear whether it will cause adverse outcomes in patients.2.During the application of ECMO, sufficient attention should be paid when cloud-like changes in the IVC are detected by echocardiography monitoring. The risk of thrombosis can be reduced by strengthening anticoagulation therapy if the disease condition permits. Echocardiography plays an important role in monitoring changes in IVC thrombosis and making treatment decisions.3.IVC filter implantation is a potential choice when the location of the thrombus matches the anchoring space. None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. The authors thank Editage (www.editage.cn) for English language editing. Additional information: Videos for this case are available under "Supplementary Data." eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4MDg0YmIwYmExYTMwM2U2M2YwNzMwMjc3NTViNjRhOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4MTcyNTU5fQ.fqnrhrEv0U9_E7sTKYyurKwpWm1qfwcSnKI9ed94u4Jg7Xa0CqW5dbgwrf800qwMyFz_8KH8VRoSavTOGI9NQf9WxC9gX7kvFb2S7QqPr3oSUAk0a5LBMYw2Z5xPEcC5aPW4a1DdSD4GDHxJVnUG_egxYvXMiUpgeQRcLDR9mRpHnk9zBD7F_8FaPF0J564eZThhZyY1rvHY5ldZRkLGxGuaJ6rvVtom44XL6kQymeC9LzxhznG7Non8CRgAiILlVCTN8y4X7wvRgE5NTU3ClENE6ePY-t-gWJSewaml82V-K60jwU1aKmU93o2LL8_dTe_XV9JiNCC7cJpD_LJpbw Download .mp4 (68.62 MB) Help with .mp4 files Video 1Tubular thrombus is seen in the inferior vena cava. The thrombus swung up and down with the force of venous return.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlM2QwMDA5NzM2MWU1YWNjZjRlYTU1Y2NjMWUxNmRkYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4MTcyNTYwfQ.j3S95fMLrrWMYBkuXhn_xZiB8DeyHk4X6xjgYM8VozG8BVMYK1bqIU_L5Am0m8RaoPnEjpsFB4KbLJMmdXckxtS0RMT2Pr7zBxDbI_JVplCgV9tw7Qheigwv8zYKUhXrml237JbSglk5haG-u96ncM4peiyftlAI_Cy_Sz5whfrj5VUPMuW9YGZib3zdx2d3-tVYi-pAMEHh4l-8sUJEt7tFv_QIn-lYUFgndDcSZ6IhCFMfm68ywBL0HHmV5Eze7rAtNf5_WT6ZcVInyfz3zvSXWCWz3fL_3yylYjVxF3sXmthE9ZkknrDelmVm5uJZ-8GaJGC3qaWZF5Cx5NqqZA Download .mp4 (0.58 MB) Help with .mp4 files Video 2The short axis of the inferior vena cava (IVC) shows the anchorage position of the descending venous filter. The thrombus is attached to the IVC filter.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjMDBmZjgzYjY0ZDUyZTI5NDUxNWVlNzQ3MGU2MjJkNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4MTcyNTYwfQ.k0A25yPbSX5jIFC5bHvnqZRqJZVa4gpZJ3UuavBhZ_P9eC_4tkCbXofvXyZPktNN5QmK0ek1rHx1DMvG8uLjlwuHGQWw6e47-G4p-7Y_2BpXyKmJ6tSvtCWESOOta5bJLFbJRUUT2t2sWg1kFztqjRFjMS7wNdrRPzDlrV9BoJxd054rYyOA5k1qTkEA4YWnPNYp4sJjECWg-XRw-UaXP4-iMHjx5Njq2IK2UKH_c5cVBgfcfRfH7u1dA5qmy2qFrWaMvXZnqX8L0jDhelRpIP7ymX-VdG3zMBcXc7GAZcACVLsegUw7f5SjkPonHtYwV-okFq6O-lP09QPABzpKHw Download .mp4 (0.77 MB) Help with .mp4 files Video 3Color Doppler image showing that the blood flow in the inferior vena cava is unobstructed, and no thrombus remains.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlNmY1ZGNmNzBhYzA3YTFjZDg0YTU4Y2I0YmEzNzE2MCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg4MTcyNTYwfQ.fqsvM3FRv6wTkze-z7_ShXX2RkI6DvYaGqanHUiVV0n_c5LcsoOpxNoRYrSM8HEA3nuNeCUhIeyr-EiFWy-G4-4QSmsshrk9s0Qseb0V5rywwLbo-Kvq1qCyc9fFNiPNVuesPSyC1SIQfebHQdz7duZ6Gh8UEbllariJZfbjQhzq5khKgziw7dPXpy3A_d_0ZcwQB8I9jKlH9tCDI6R1Lfk6TNdzV1Lh9FydVybjEyPkSiAjnBwnACmMpPG0B6NoJE1OhMq9H-fZnU-BoF5jA2HXgOfUCDSCnCAm-HiqoR8-e3-ztzQ22zZC1A-1nE5hsv4dHhNms4F8pZtX8LL31g Download .mp4 (1.65 MB) Help with .mp4 files Video 4