VV-ECMO cannulation-related right brachiocephalic vein injury associated with pleural empyema.
Akira Kono, Philip Hawke, Koichi Haruta et al.
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Case in brief
An 82-year-old man with acute respiratory distress syndrome from pleural empyema and lung abscess required VV-ECMO for worsening acidemia and hypoxemia. During internal jugular cannulation, purulent fluid emerged from the outflow catheter. CT showed that the catheter had perforated the right brachiocephalic vein and formed a fistula into the pleural empyema. ECMO support was re-established with an alternative configuration, and the vein was surgically repaired. The patient gradually recovered and was discharged ambulatory.
What made this case unusual
The catheter perforated the brachiocephalic vein and fistulized into an existing pleural empyema; the authors note that this occurred without congenital anomalies and suggest inflammation-related vascular fragility may have contributed.
Diagnostic / clinical pearl
When purulent fluid appears during VV-ECMO cannulation, consider catheter injury communicating with intrathoracic infection; CT can identify the perforation and fistula.
Why it matters
Intrathoracic pathology, including pleural empyema, should be considered when selecting an ECMO cannulation configuration.