Inserting a VA-ECMO Cannula Through an Inferior Vena Cava Filter During Extracorporeal Cardiopulmonary Resuscitation

Inserting a VA-ECMO Cannula Through an Inferior Vena Cava Filter During Extracorporeal Cardiopulmonary Resuscitation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Inserting a VA-ECMO Cannula Through an Inferior Vena Cava Filter During Extracorporeal Cardiopulmonary Resuscitation Gen hua Mu, Rongliang Xu, Yiyun Wang, Chun Pan, Jianfeng Xie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5146272/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Dec, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted 11 You are reading this latest preprint version Abstract Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been utilized to treat massive pulmonary embolism (PE) accompanied by cardiac arrest or refractory cardiogenic shock. Our team preferred a femoral-femoral approach for vascular cannulation, using drainage and return cannulas in the common femoral vein and artery, respectively. However, femoral venous cannulation can be limited or challenging due to the presence of thrombus in the inferior vena cava (IVC), making the insertion of the drainage cannula via the femoral vein difficult. We present the case of a patient with massive PE who underwent aspiration thrombectomy and insertion of an IVC filter, followed by the initiation of VA-ECMO for cardiac arrest. We successfully inserted a femoral venous return ECMO cannula through the inferior vena cava filter during extracorporeal cardiopulmonary resuscitation. The patient stabilized with these interventions and ultimately achieved a favorable outcome with normal neurological status. Case Report VA-ECMO Inferior Vena Cava Filter Extracorporeal Cardiopulmonary Resuscitation Pulmonary Embolism Figures Figure 1 Figure 2 Figure 3 1. Introduction Acute pulmonary embolism (PE) is a significant cause of mortality worldwide. Most deaths from acute PE occur within the first several hours to days, with over 70% of fatalities happening within the first hour. Massive PE accounts for approximately 4.5–10% of all PE cases and is associated with substantial morbidity and mortality, exceeding 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been utilized to treat massive pulmonary embolism in patients experiencing cardiac arrest or cardiogenic shock that is refractory to standard treatments [ 1 ] . However, there are limited reports on the insertion of ECMO cannulas via the femoral vein in patients with inferior vena cava filters. We present the case of a patient with massive PE who underwent aspiration thrombectomy and placement of an inferior vena cava (IVC) followed by by the of VA-ECMO due to arrest. 2. Presentation of case A 42-year-old woman at the emergency department presented with worsening shortness of breath for more than 1 hour. She underwent uterine fibroidectomy 10 days prior and received low-molecular-weight heparin for the treatment of postoperative deep venous thrombosis. On examination, her blood pressure was 110/70 mmHg, her heart rate was 148 beats/minute, her respiratory rate was 25 breaths/minute, and her oxygen saturation was 85% while she was breathing ambient air. Initial laboratory results showed elevated D-dimer (1595 ng/mL) and lactate (4.5 mmol/L) levels. Computed tomography pulmonary angiography (CTPA) revealed extensive pulmonary embolism involving the bilateral main pulmonary arteries and branches. The Pulmonary Embolism Severity Index (PESI) predicted a 10-24.5% risk of 30-day mortality. The patient was then transferred to the Interventional Center, after which aspiration thrombectomy was performed. The inferior vena cava (IVC) filter was successfully deployed under fluoroscopy at the level of the L1-L2 vertebrae (Fig. 1 ). However, the patient's hypoxia worsened after the intervention. Oxygen saturation decreased to 81%, when the oxygen therapy was face mask at 10L/min. Tracheal intubation and invasive mechanical ventilation were performed immediately. Five minutes later, she had a cardiac arrest, and cardiopulmonary resuscitation (CPR)was initiated. With CPR in progress, VA-ECMO was initiated by the critical care team. A blind percutaneous femoral-femoral access technique was used, with a 21-Fr femoral venous cannula and a 17-Fr femoral arterial cannula. There was concern regarding cannulation due to her IVC filter. Placement was confirmed by abdominal X-ray. X-ray imaging revealed IVC filter migration with severe deformity (Fig. 2 ). The initial ECMO flow was 4 L/m 2 /min. She was anticoagulated with heparin infusion during ECMO within the APTT targets (40-60s). She improved clinically and was successfully weaned from ECMO on Day 7. During her ICU stay, she was complicated by respiratory failure requiring tracheostomy. On Day 15, she recovered and was discharged to another hospital for rehabilitation. The filter could not be retrieved, as it was deformed and firmly attached to the vascular wall (Fig. 3 ). Warfarin was used to prevent IVC filter thrombosis. At her 2-month follow-up, the patient had a normal neurological outcome, and was satisfied with the care she had received. 3. Discussion Pulmonary embolism is a common and potentially fatal cardiovascular disorder [ 2 ] . Previous studies have indicated that all-cause hospital mortality in patients with massive PE ranges from 44 to 65% [ 3 , 4 ] . The mainstay of acute PE treatment is anticoagulation therapy. Patients with massive pulmonary embolism require advanced therapy for pulmonary artery reperfusion [ 5 ] . In cases of cardiac arrest or cardiogenic shock refractory to standard treatment, mechanical haemodynamic support, such as VA-ECMO, may be considered [ 6 ] . The femoro-femoral approach is preferred for vascular cannulation when the drainage cannula is inserted via the femoral vein and threaded up until its distal tip is 1–2 cm below the cavoatrial junction, after which the return cannula is preferably inserted into the femoral artery [ 6 ] . The limitation of these cannulation techniques is that if there is any obstruction in the IVC, access to the optimal location at the inferior cavoatrial junction will be prevented. In patients with IVC filters, inserting drainage cannulas via the femoral vein is difficult. Ngoc Minh Le et al. presented a patient who had been diagnosed with COVID-19 and developed deep vein thrombosis [ 7 ] . An IVC filter was placed to prevent fatal pulmonary embolism. Her respiratory failure subsequently deteriorated, and she needed veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a rescue therapy. Since the IVC filter impedes the femoral cannula, a double-lumen jugular cannula was inserted successfully. This case indicated that when a patient with IVC filters is treated with VA-ECMO, inserting a jugular venous cannula, draining from the right atrium and infusing into the femoral artery is an option. Dhaval Pau et al. reported the case of a pneumonia patient with severe respiratory failure requiring VV-ECMO. The patient had a previously placed inferior vena cava filter for unclear reasons. Under the guidance of transesophageal echocardiography and fluoroscopy, jugular and femoral vein cannulas were inserted without dislodgement of the IVC filter [ 8 ] . Therefore, ultrasound or interventional guidance is a feasible way to help femoral vein cannulas pass through the IVC filter. In addition, the choice of a thinner venous drainage catheter may also increase the success rate of the catheter through the IVC filter. Dhaval Pau et al. suggested inserting a femoral vein cannula with the tip below the filter as another option [ 8 ] . However, this method might result in poor drainage and unstable and low ECMO flow. To the best of our knowledge, this is the first case of femoral-femoral cannulation through an existing IVC filter during extracorporeal cardiopulmonary resuscitation (ECPR). Notably, percutaneous blind insertion of VA-ECMO cannulas through the IVC filter carries potential complications, such as filter migration, tilt and deformity. Therefore, in adult patients with inferior vena cava filters, how to choose an optimal VA-ECMO cannulation site needs to be carefully considered and studied. 4. Conclusion In patients with IVC filters, inserting drainage cannula via femoral vein may be feasible during extracorporeal cardiopulmonary resuscitation. Declarations Ethical Approval This case report is approved by the Ethics Committee of Yancheng No.1 People's Hospital. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution GM, JX conceived and designed this study.RX collected the data. YW,and CP prepared the manuscript. All authors critically revised the manuscript and approved the final version. Acknowledgement The authors thank all nurses, residents, and other personnel of the participating department for their generous cooperation. References Martinez Licha CR, McCurdy CM, Maldonado SM, Lee LS. Current Management of Acute Pulmonary Embolism. Ann Thorac Cardiovasc Surg. 2020 Apr 20;26(2):65-71. Duffett L, Castellucci LA, Forgie MA. Pulmonary embolism: update on management and controversies. BMJ. 2020 Aug 5;370:m2177. Smith S B, Geske J B, Kathuria P. Analysis of national trends in admissions for pulmonary embolism. Chest. 2016;150(01):35-45. ESC Scientific Document Group . Konstantinides S V, Meyer G, Becattini C. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS) Eur Heart J. 2020;41 04:543-603. Polaková E, Veselka J. Management of Massive Pulmonary Embolism. Int J Angiol. 2022 Sep 23;31(3):194-197. Hobohm L, Sagoschen I, Habertheuer A, Barco S, Valerio L, Wild J, Schmidt FP, Gori T, Münzel T, Konstantinides S, Keller K. Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism. Resuscitation. 2022 Jan;170:285-292. Le NM, Dang UT, Vu HV, Nguyen HL. Bicaval dual lumen cannula placement using transthoracic echocardiography in COVID-19 scenario: pearls and pitfalls. BMJ Case Rep. 2022 Jun 15;15(6):e249195. Pau D, Kasal J, Plisco M. Venovenous ECMO cannulation in a patient with a pre-existing IVC filter. Intensive Care Med. 2018 Sep;44(9):1573-1574. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Dec, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 06 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviews received at journal 06 Nov, 2024 Reviewers agreed at journal 27 Oct, 2024 Reviews received at journal 24 Oct, 2024 Reviewers agreed at journal 22 Oct, 2024 Reviewers agreed at journal 22 Oct, 2024 Reviewers invited by journal 22 Oct, 2024 Editor assigned by journal 25 Sep, 2024 Submission checks completed at journal 25 Sep, 2024 First submitted to journal 24 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5146272","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":375108215,"identity":"562e7b6b-0bc4-49be-a86e-4f62e0482d6a","order_by":0,"name":"Gen hua Mu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYLACxgYGBn5mxsYHHwxs7IjXItnefNhwRkFaMvFaDM4cS5Pm+XAIxMYPdGekX3xcuOOwPMONHDNpG4MDzAzsh49uwKfF7EZOsfHMM4cNG2fkGFvnGNzhY+BJS7tBQEuaNG/bYcZmiRzD2zkGz5gZJHjMCGlJ/w3UYt8mkWMgbWFwmLGBsJb0Y8xALYk9PMeSpBmI0nLmDTPQYenJM9iBgdxjkJbMRtAvx9MffuZts7bdfxgYlT/+2Njxsx8+hlcLAwOPASqfDb9yEGB/QFjNKBgFo2AUjGwAAObYT7GWx+2cAAAAAElFTkSuQmCC","orcid":"","institution":"Zhongda Hospital Southeast University","correspondingAuthor":true,"prefix":"","firstName":"Gen","middleName":"hua","lastName":"Mu","suffix":""},{"id":375108216,"identity":"e0aa5f7f-0f24-45fd-8745-31c92a40fe02","order_by":1,"name":"Rongliang Xu","email":"","orcid":"","institution":"Yancheng NO.1 People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rongliang","middleName":"","lastName":"Xu","suffix":""},{"id":375108217,"identity":"c2150e52-0e58-4188-bc0f-7df3ec6597b3","order_by":2,"name":"Yiyun Wang","email":"","orcid":"","institution":"Zhongda Hospital Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Yiyun","middleName":"","lastName":"Wang","suffix":""},{"id":375108218,"identity":"e8fadba5-7968-4795-b2a3-d93e01b2a740","order_by":3,"name":"Chun Pan","email":"","orcid":"","institution":"Sichuan Academy of Medical Sciences \u0026 Sichuan Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chun","middleName":"","lastName":"Pan","suffix":""},{"id":375108219,"identity":"bf2bb580-e6c8-4a26-b69f-ce4eb9f544b6","order_by":4,"name":"Jianfeng Xie","email":"","orcid":"","institution":"Zhongda Hospital Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Jianfeng","middleName":"","lastName":"Xie","suffix":""}],"badges":[],"createdAt":"2024-09-24 15:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5146272/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5146272/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-024-00789-w","type":"published","date":"2024-12-18T15:57:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69850515,"identity":"73e810dc-8443-46ec-87f8-8aaaf13f3d1f","added_by":"auto","created_at":"2024-11-25 23:27:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":113976,"visible":true,"origin":"","legend":"\u003cp\u003eThe IVC filter was deployed at the level of the L1-L2 vertebrae.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5146272/v1/f85999f37ca70a8ba0ee3319.png"},{"id":69850839,"identity":"164617bf-16c4-4056-b413-112b3b55b123","added_by":"auto","created_at":"2024-11-25 23:35:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":124584,"visible":true,"origin":"","legend":"\u003cp\u003eECMO cannula traversed the IVC filter, and led to filter migration and deformity.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5146272/v1/5da781505c78088d3e061109.png"},{"id":69850516,"identity":"47ce184c-9bdb-44cf-b212-7c413d1ea60f","added_by":"auto","created_at":"2024-11-25 23:27:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":55068,"visible":true,"origin":"","legend":"\u003cp\u003eThe 3D reconstructed image showed the deformed IVC filter in the IVC.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5146272/v1/2a38eed8b95e80ac4ca240b3.png"},{"id":72201897,"identity":"16e80824-19ce-4dc2-a371-d9a7be4413fa","added_by":"auto","created_at":"2024-12-23 16:11:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":492785,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5146272/v1/330b499c-029e-44ed-a252-f51849ccd779.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Inserting a VA-ECMO Cannula Through an Inferior Vena Cava Filter During Extracorporeal Cardiopulmonary Resuscitation","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAcute pulmonary embolism (PE) is a significant cause of mortality worldwide. Most deaths from acute PE occur within the first several hours to days, with over 70% of fatalities happening within the first hour. Massive PE accounts for approximately 4.5\u0026ndash;10% of all PE cases and is associated with substantial morbidity and mortality, exceeding 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been utilized to treat massive pulmonary embolism in patients experiencing cardiac arrest or cardiogenic shock that is refractory to standard treatments\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. However, there are limited reports on the insertion of ECMO cannulas via the femoral vein in patients with inferior vena cava filters. We present the case of a patient with massive PE who underwent aspiration thrombectomy and placement of an inferior vena cava (IVC) followed by by the of VA-ECMO due to arrest.\u003c/p\u003e"},{"header":"2. Presentation of case","content":"\u003cp\u003eA 42-year-old woman at the emergency department presented with worsening shortness of breath for more than 1 hour. She underwent uterine fibroidectomy 10 days prior and received low-molecular-weight heparin for the treatment of postoperative deep venous thrombosis. On examination, her blood pressure was 110/70 mmHg, her heart rate was 148 beats/minute, her respiratory rate was 25 breaths/minute, and her oxygen saturation was 85% while she was breathing ambient air. Initial laboratory results showed elevated D-dimer (1595 ng/mL) and lactate (4.5 mmol/L) levels. Computed tomography pulmonary angiography (CTPA) revealed extensive pulmonary embolism involving the bilateral main pulmonary arteries and branches. The Pulmonary Embolism Severity Index (PESI) predicted a 10-24.5% risk of 30-day mortality.\u003c/p\u003e \u003cp\u003eThe patient was then transferred to the Interventional Center, after which aspiration thrombectomy was performed. The inferior vena cava (IVC) filter was successfully deployed under fluoroscopy at the level of the L1-L2 vertebrae (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, the patient's hypoxia worsened after the intervention. Oxygen saturation decreased to 81%, when the oxygen therapy was face mask at 10L/min. Tracheal intubation and invasive mechanical ventilation were performed immediately. Five minutes later, she had a cardiac arrest, and cardiopulmonary resuscitation (CPR)was initiated. With CPR in progress, VA-ECMO was initiated by the critical care team. A blind percutaneous femoral-femoral access technique was used, with a 21-Fr femoral venous cannula and a 17-Fr femoral arterial cannula. There was concern regarding cannulation due to her IVC filter. Placement was confirmed by abdominal X-ray. X-ray imaging revealed IVC filter migration with severe deformity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The initial ECMO flow was 4 L/m\u003csup\u003e2\u003c/sup\u003e/min. She was anticoagulated with heparin infusion during ECMO within the APTT targets (40-60s). She improved clinically and was successfully weaned from ECMO on Day 7. During her ICU stay, she was complicated by respiratory failure requiring tracheostomy. On Day 15, she recovered and was discharged to another hospital for rehabilitation. The filter could not be retrieved, as it was deformed and firmly attached to the vascular wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Warfarin was used to prevent IVC filter thrombosis. At her 2-month follow-up, the patient had a normal neurological outcome, and was satisfied with the care she had received.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003ePulmonary embolism is a common and potentially fatal cardiovascular disorder \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Previous studies have indicated that all-cause hospital mortality in patients with massive PE ranges from 44 to 65%\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. The mainstay of acute PE treatment is anticoagulation therapy. Patients with massive pulmonary embolism require advanced therapy for pulmonary artery reperfusion\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. In cases of cardiac arrest or cardiogenic shock refractory to standard treatment, mechanical haemodynamic support, such as VA-ECMO, may be considered\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe femoro-femoral approach is preferred for vascular cannulation when the drainage cannula is inserted via the femoral vein and threaded up until its distal tip is 1\u0026ndash;2 cm below the cavoatrial junction, after which the return cannula is preferably inserted into the femoral artery\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. The limitation of these cannulation techniques is that if there is any obstruction in the IVC, access to the optimal location at the inferior cavoatrial junction will be prevented. In patients with IVC filters, inserting drainage cannulas via the femoral vein is difficult.\u003c/p\u003e \u003cp\u003eNgoc Minh Le et al. presented a patient who had been diagnosed with COVID-19 and developed deep vein thrombosis\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. An IVC filter was placed to prevent fatal pulmonary embolism. Her respiratory failure subsequently deteriorated, and she needed veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a rescue therapy. Since the IVC filter impedes the femoral cannula, a double-lumen jugular cannula was inserted successfully. This case indicated that when a patient with IVC filters is treated with VA-ECMO, inserting a jugular venous cannula, draining from the right atrium and infusing into the femoral artery is an option.\u003c/p\u003e \u003cp\u003eDhaval Pau et al. reported the case of a pneumonia patient with severe respiratory failure requiring VV-ECMO. The patient had a previously placed inferior vena cava filter for unclear reasons. Under the guidance of transesophageal echocardiography and fluoroscopy, jugular and femoral vein cannulas were inserted without dislodgement of the IVC filter\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Therefore, ultrasound or interventional guidance is a feasible way to help femoral vein cannulas pass through the IVC filter. In addition, the choice of a thinner venous drainage catheter may also increase the success rate of the catheter through the IVC filter. Dhaval Pau et al. suggested inserting a femoral vein cannula with the tip below the filter as another option\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. However, this method might result in poor drainage and unstable and low ECMO flow.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first case of femoral-femoral cannulation through an existing IVC filter during extracorporeal cardiopulmonary resuscitation (ECPR). Notably, percutaneous blind insertion of VA-ECMO cannulas through the IVC filter carries potential complications, such as filter migration, tilt and deformity. Therefore, in adult patients with inferior vena cava filters, how to choose an optimal VA-ECMO cannulation site needs to be carefully considered and studied.\u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003eIn patients with IVC filters, inserting drainage cannula via femoral vein may be feasible during extracorporeal cardiopulmonary resuscitation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthical Approval\u003c/strong\u003e \u003cp\u003eThis case report is approved by the Ethics Committee of Yancheng No.1 People's Hospital.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGM, JX conceived and designed this study.RX collected the data. YW,and CP prepared the manuscript. All authors critically revised the manuscript and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank all nurses, residents, and other personnel of the participating department for their generous cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMartinez Licha CR, McCurdy CM, Maldonado SM, Lee LS. Current Management of Acute Pulmonary Embolism. Ann Thorac Cardiovasc Surg. 2020 Apr 20;26(2):65-71.\u003c/li\u003e\n\u003cli\u003eDuffett L, Castellucci LA, Forgie MA. Pulmonary embolism: update on management and controversies. BMJ. 2020 Aug 5;370:m2177.\u003c/li\u003e\n\u003cli\u003eSmith S B, Geske J B, Kathuria P. Analysis of national trends in admissions for pulmonary embolism. Chest. 2016;150(01):35-45.\u003c/li\u003e\n\u003cli\u003eESC Scientific Document Group . Konstantinides S V, Meyer G, Becattini C. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS) Eur Heart J. 2020;41 04:543-603.\u003c/li\u003e\n\u003cli\u003ePolakov\u0026aacute; E, Veselka J. Management of Massive Pulmonary Embolism. Int J Angiol. 2022 Sep 23;31(3):194-197. \u003c/li\u003e\n\u003cli\u003eHobohm L, Sagoschen I, Habertheuer A, Barco S, Valerio L, Wild J, Schmidt FP, Gori T, M\u0026uuml;nzel T, Konstantinides S, Keller K. Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism. Resuscitation. 2022 Jan;170:285-292.\u003c/li\u003e\n\u003cli\u003eLe NM, Dang UT, Vu HV, Nguyen HL. Bicaval dual lumen cannula placement using transthoracic echocardiography in COVID-19 scenario: pearls and pitfalls. BMJ Case Rep. 2022 Jun 15;15(6):e249195.\u003c/li\u003e\n\u003cli\u003ePau D, Kasal J, Plisco M. Venovenous ECMO cannulation in a patient with a pre-existing IVC filter. Intensive Care Med. 2018 Sep;44(9):1573-1574. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Case Report, VA-ECMO, Inferior Vena Cava Filter, Extracorporeal Cardiopulmonary Resuscitation, Pulmonary Embolism","lastPublishedDoi":"10.21203/rs.3.rs-5146272/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5146272/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eVenoarterial extracorporeal membrane oxygenation (VA-ECMO) has been utilized to treat massive pulmonary embolism (PE) accompanied by cardiac arrest or refractory cardiogenic shock. Our team preferred a femoral-femoral approach for vascular cannulation, using drainage and return cannulas in the common femoral vein and artery, respectively. However, femoral venous cannulation can be limited or challenging due to the presence of thrombus in the inferior vena cava (IVC), making the insertion of the drainage cannula via the femoral vein difficult. We present the case of a patient with massive PE who underwent aspiration thrombectomy and insertion of an IVC filter, followed by the initiation of VA-ECMO for cardiac arrest. We successfully inserted a femoral venous return ECMO cannula through the inferior vena cava filter during extracorporeal cardiopulmonary resuscitation. The patient stabilized with these interventions and ultimately achieved a favorable outcome with normal neurological status.\u003c/p\u003e","manuscriptTitle":"Inserting a VA-ECMO Cannula Through an Inferior Vena Cava Filter During Extracorporeal Cardiopulmonary Resuscitation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-25 23:27:12","doi":"10.21203/rs.3.rs-5146272/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-07T04:33:42+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"285551080512595580209462704369415331063","date":"2024-11-07T04:30:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-06T17:11:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91832387760366551426802726310121020394","date":"2024-10-27T14:40:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-24T08:15:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206387303817543295854198656810238282813","date":"2024-10-22T14:27:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70654423035551368866575660301794353762","date":"2024-10-22T13:51:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-22T13:33:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-26T01:38:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-26T01:37:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2024-09-24T15:10:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"388b8209-b222-4e31-be60-782f88714fbc","owner":[],"postedDate":"November 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:03:43+00:00","versionOfRecord":{"articleIdentity":"rs-5146272","link":"https://doi.org/10.1186/s12245-024-00789-w","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2024-12-18 15:57:54","publishedOnDateReadable":"December 18th, 2024"},"versionCreatedAt":"2024-11-25 23:27:12","video":"","vorDoi":"10.1186/s12245-024-00789-w","vorDoiUrl":"https://doi.org/10.1186/s12245-024-00789-w","workflowStages":[]},"version":"v1","identity":"rs-5146272","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5146272","identity":"rs-5146272","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}