Inserting a VA-ECMO Drainage Cannula into the Inferior Vena Cava through the Internal Jugular Vein in a Patient with an IVC Filter

Inserting a VA-ECMO Drainage Cannula into the Inferior Vena Cava through the Internal Jugular Vein in a Patient with an IVC Filter | 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 Drainage Cannula into the Inferior Vena Cava through the Internal Jugular Vein in a Patient with an IVC Filter Xin Zhao, Jiaxin Xu, Zhizhong Yu, Dan Xu, Hong Liu, Jiancheng Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7144652/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Oct, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted 13 You are reading this latest preprint version Abstract Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a critical treatment for patients with massive pulmonary embolism (PE) complicated by refractory cardiogenic shock. In this case, an inferior vena cava (IVC) filter and iliac vein thrombosis posed a risk of filter migration with conventional femoral venous access, necessitating an alternative drainage approach. We treated an 18-year-old male with hereditary thrombophilia due to a prothrombin gene (F2) mutation who presented with acute massive PE and obstructive shock. Following emergency pulmonary artery thrombectomy and IVC filter placement, VA-ECMO was initiated using right internal jugular vein cannulation for venous drainage and femoral artery cannulation for arterial return. Hemodynamic stability was rapidly achieved, allowing successful weaning and decannulation within 96 hours. The patient was discharged on postoperative day 11 without neurological complications. This case demonstrates that jugular-to-IVC cannulation is a feasible and effective VA-ECMO drainage strategy for patients with existing IVC filters, avoiding mechanical complications associated with filter traversal. Inferior vena cava filter VA-ECMO Obstructive shock VTE Figures Figure 1 Figure 2 Introduction In addition to standard anticoagulation therapy [1], the placement of inferior vena cava (IVC) filters is a well-established intervention that effectively prevents further embolization of deep vein thrombosis (DVT) and reduces the risk of pulmonary embolism (PE), thereby significantly lowering the recurrence rate of this potentially life-threatening complication [2, 3]. However, when venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is required in patients with an existing IVC filter, careful selection of the cannulation route becomes essential. This case report describes a patient with acute massive PE caused by thrombus detachment from lower extremity DVT secondary to thrombophilia, complicated by obstructive shock. The patient was urgently initiated on VA-ECMO. Due to the presence of a pre-existing IVC filter, internal jugular vein cannulation was selected for venous drainage, with the catheter traversing the superior vena cava and right atrium to reach the inferior vena cava. Presentation of case An 18-year-old male patient, a Moroccan international student in China, presented to the emergency department of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, with a chief complaint of persistent upper abdominal pain for one week that had worsened over the past 24 hours, accompanied by dyspnea, nausea, and vomiting. On physical examination, he exhibited signs of acute illness, drowsiness, tachypnea (respiratory rate (RR): 40 breaths/min), severe hypoxemia (peripheral oxygen saturation (SpO₂): 80%), hypotension (blood pressure (BP): 80/30 mmHg), tachycardia (heart rate (HR): 120 beats/min), arrhythmia with frequent premature beats, and peripheral cyanosis. Immediate intravenous infusion of vasoactive agents was initiated to stabilize hemodynamics. Transthoracic echocardiography (TTE) revealed pulmonary artery dilation with severe pulmonary hypertension, right ventricular (RV) enlargement, diffuse RV hypokinesis, severe tricuspid regurgitation, a high-density intraluminal shadow at the origin of the left pulmonary artery, and dilated inferior vena cava. Lower limb ultrasound demonstrated iliac vein thrombosis. No significant abnormalities were identified on head, chest, and abdominal CT scans. Subsequently, emergency computed tomographic angiography (CTA) of the entire aorta and pulmonary arteries was performed, revealing multiple filling defects involving both main pulmonary arteries and their branches, more prominently on the right side, consistent with acute PE. An urgent consultation with the interventional radiology team was requested immediately. The patient’s condition deteriorated rapidly, with progressive decline in consciousness, SpO₂, and BP. His Pulmonary Embolism Severity Index (PESI) score was calculated as 180, corresponding to risk class V, indicating an extremely high mortality risk. Emergency interventions including pulmonary artery thrombectomy, inferior vena cava filter placement, iliac vein thrombectomy, pulmonary angiography, and inferior vena cava angiography were promptly carried out. Angiographic findings confirmed patent inferior vena cava with unobstructed flow; however, scattered filling defects were observed in the main pulmonary arteries and their branches, predominantly on the right side, with significantly impaired blood flow (Fig 1A). An umbrella-type inferior vena cava filter was urgently deployed (Fig 1B), followed by pulmonary artery thrombectomy. Post-procedural angiography demonstrated a marked reduction in filling defects within the main right pulmonary artery and some of its branches, along with improved blood flow velocity. Due to the patient’s extremely critical condition, he was urgently transferred to the intensive care unit (ICU) for further life-supporting interventions following the completion of interventional procedures. Upon ICU admission, the patient was in a state of shallow coma with tachypnea. Cardiopulmonary monitoring revealed a HR of 133 beats/min, RR of 27 breaths/min, BP of 131/71 mmHg (maintained with norepinephrine infusion at 0.17 μg/kg/min), and SpO₂ of 68%. Physical examination showed cyanosis of the lips, coarse bilateral lung sounds on auscultation, and arrhythmia. Emergency endotracheal intubation was performed, and invasive mechanical ventilation was initiated using synchronized intermittent mandatory ventilation (SIMV) mode (FiO₂ 1.0, tidal volume 500 mL, RR 24 breaths/min, PEEP 8 cmH₂O). Concurrently, analgesia and sedation were administered, and the norepinephrine dose was increased to 0.3 μg/kg/min to support hemodynamics. Initial arterial blood gas analysis demonstrated severe acidosis: pH 6.95, PaO₂ 71 mmHg, PaCO₂ 67 mmHg, lactate 9.4 mmol/L, base excess –18.3 mmol/L. Intravenous administration of 5% sodium bicarbonate was promptly initiated to correct metabolic acidosis, resulting in an improvement of SpO₂ to approximately 90%. However, one hour later, SpO₂ declined gradually to 84%, and BP decreased to 80/60 mmHg despite ongoing norepinephrine infusion at 0.3 μg/kg/min. Repeat arterial blood gas analysis showed: pH 7.23, PaO₂ 50 mmHg, PaCO₂ 62 mmHg, lactate 6.7 mmol/L, HCO₃⁻ 26.0 mmol/L, FiO₂ 1.0. TTE revealed RV dilation with a right ventricle/left ventricle ratio greater than 1 (Video 1, Video 2). Considering concomitant hematuria, prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT), and the high risk of systemic bleeding associated with thrombolytic therapy, the decision was made—after obtaining informed consent from the patient’s family—to initiate emergency VA-ECMO. Ultrasound-guided percutaneous cannulation was performed, including placement of a 22-French right internal jugular vein drainage catheter and a 19-French femoral artery return catheter. The tip of the drainage catheter was positioned above the hepatic vein confluence within the inferior vena cava. Real-time ultrasound guidance was used during insertion, and final catheter positioning was confirmed by chest X-ray and bedside echocardiography (Fig 2, Video 3). The initial ECMO flow was set at 3 L/m²/min. During VA-ECMO support, anticoagulation with unfractionated heparin was administered to maintain APTT between 50–60 seconds, while norepinephrine was continuously infused to maintain mean arterial pressure above 65 mmHg. Following initiation of VA-ECMO, the patient’s clinical status gradually improved. Endotracheal extubation was performed on day 3 post-ICU admission, followed by transition to high-flow nasal cannula oxygen therapy. From day 3 to day 5, as cardiac function and hemodynamic parameters stabilized, ECMO support was progressively weaned and ultimately discontinued. On day 7, the patient was switched to low-flow nasal oxygen with stable vital signs. He was transferred to the Department of Respiratory Medicine on day 9 and discharged uneventfully on day 11. Subsequent genetic testing via next-generation sequencing identified a mutation in the F2 gene, confirming the diagnosis of hereditary thrombophilia. Lifelong oral anticoagulation with rivaroxaban was prescribed. Follow-up evaluations indicated that the patient had successfully resumed normal daily activities. Discussion Thrombophilia refers to a hereditary or acquired condition characterized by defects in anticoagulant proteins, coagulation factors, or fibrinolytic proteins, or the presence of acquired risk factors that predispose individuals to thromboembolic events, primarily venous thromboembolism (VTE) [ 4 ]. Based on clinical manifestations, physical findings, and laboratory evidence, thrombophilia is generally categorized into two major types: hereditary and acquired. Among hereditary forms, the prothrombin gene (F2) G20210A mutation ranks as the second most common genetic risk factor after factor V Leiden mutation. This mutation contributes to a hypercoagulable state by increasing plasma prothrombin levels by approximately 30% [ 5 , 6 ]. The prevalence of this mutation is approximately 2–4% in European and American populations, whereas it is exceedingly rare (< 0.5%) among Asian and African populations. 4 More than 10% of the general population carries at least one identifiable hereditary thrombophilia variant, and such conditions are responsible for at least one-third of all VTE cases [ 7 ]. Furthermore, approximately one-third of patients with DVT will develop concurrent PE [ 8 ]. The global annual incidence of PE ranges from 39 to 115 per 100,000 individuals [ 9 ]. Massive PE accounts for approximately 4.5–10% of all PE cases and is associated with mortality rates exceeding 50% [ 10 ]. In such critically ill patients, VA-ECMO can serve as a valuable hemodynamic support strategy. Although VA-ECMO does not directly remove pulmonary arterial thrombi, it alleviates RV preload, reduces RV dilation, and enhances right coronary perfusion, thereby providing a critical window for thrombus resolution [ 11 , 12 ]. In patients requiring venovenous ECMO (VV-ECMO) who have previously undergone inferior vena cava (IVC) filter placement, the use of double-lumen catheters via the internal jugular vein represents a preferable alternative. Ngoc Minh Le et al. reported a case involving a patient with COVID-19 and concomitant DVT who successfully underwent VV-ECMO following IVC filter implantation [ 13 ]. Due to obstruction caused by the filter, femoral vein cannulation was not feasible, prompting successful insertion of a double-lumen jugular catheter. However, in patients undergoing VV-ECMO or VA-ECMO with pre-existing IVC filters, conventional peripheral cannulation via the femoral vein-femoral artery route presents significant technical challenges and risks [ 14 ]. Dhaval Pau et al. described a case of severe pneumonia-induced respiratory failure requiring VV-ECMO in a patient with a prior IVC filter. Under transesophageal echocardiography (TEE) and fluoroscopic guidance, both jugular and femoral vein access were achieved without filter displacement [ 15 ]. However, a report from Nanjing Drum Tower Hospital, Southeast University, documented a case of massive PE treated with thrombectomy and IVC filter placement followed by VA-ECMO during cardiac arrest. During extracorporeal cardiopulmonary resuscitation, femoral vein cannulation through the IVC filter was technically feasible but resulted in filter migration, tilting, and structural deformation [ 16 ]. In our case, the patient had an umbrella-type IVC filter and confirmed lower extremity DVT, making femoral vein cannulation highly risky. Therefore, an alternative cannulation strategy was urgently required. Our team successfully performed TTE-guided placement of a single-lumen drainage catheter via the right internal jugular vein, with the tip positioned within the inferior vena cava, combined with femoral artery return cannulation for VA-ECMO support. This approach enabled effective management of massive PE without compromising filter integrity. Conclusion For patients with pre-existing IVC filters, internal jugular vein cannulation for VA-ECMO drainage via placement of a single-lumen catheter into the inferior vena cava is technically feasible. Declarations Acknowledgements The authors thank all nurses, attending physicians, and healthcare staff from for their dedicated support. Author contributions J. C. Z. and X. Z. conceptualized the case report, conducted the literature review, drafted the initial manuscript, and critically reviewed and revised the manuscript. X. Z., J. X. X., Z. Z. Y., and D. X. were responsible for data acquisition and figure editing. H. L. contributed expert input during the critical review and revision of the manuscript. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability No datasets were generated or analysed during the current study. Consent for publication The patient consented to the publishing of all images, clinical data, and other data included in the manuscript. Competing interests The authors declare no competing interests. References Khorana AA, Mackman N, Falanga A, Pabinger I, Noble S, Ageno W, et al. Cancer-associated venous thromboembolism. Nat Rev Dis Primers. 2022;8(1):11. Martinez LC, Mccurdy CM, Maldonado SM, Lee LS. Current management of acute pulmonary embolism. Ann Thorac Cardiovasc Surg. 2020;26(2):65–71. Duffett L. Deep venous thrombosis. Ann Intern Med. 2022;175(9):ITC129–44. 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;15(6):e249195. Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, et al. Antithrombotic therapy for vte disease: second update of the chest guideline and expert panel report. Chest. 2021;160(6):e545–608. . Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the prepic (prevention du risque d'embolie pulmonaire par interruption cave) randomized study. Circulation. 2005;112(3):416–22. Lorusso R, Shekar K, Maclaren G, Schmidt M, Pellegrino V, Meyns B, et al. Elso interim guidelines for venoarterial extracorporeal membrane oxygenation in adult cardiac patients. Asaio J. 2021;67(8):827–44. Wendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res. 2016;118(9):1340–7. Mcguire WC, Sullivan L, Odish MF, Desai B, Morris TA, Fernandes TM. Management strategies for acute pulmonary embolism in the icu. Chest. 2024;166(6):1532–45. Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of vte in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e227S–e277S. Zhang L, Cao H, Chen Y, Jiao G. Risk factors for venous thromboembolism following spinal surgery: a meta-analysis. Medicine (Baltimore). 2020;99(29):e20954. Essien EO, Rali P, Mathai SC. Pulmonary embolism. Med Clin North Am. 2019;103(3):549–64. Bauer KA. The thrombophilias: well-defined risk factors with uncertain therapeutic implications. Ann Intern Med. 2001;135(5):367–73. Connors JM. Thrombophilia testing and venous thrombosis. N Engl J Med. 2017;377(12):1177–87. Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, et al. Use of extracorporeal circulation (ecls/ecmo) for cardiac and circulatory failure -a clinical practice guideline level 3. Esc Heart Fail. 2022;9(1):506–18. Pau D, Kasal J, Plisco M. Venovenous ecmo cannulation in a patient with a pre-existing ivc filter. Intensive Care Med. 2018;44(9):1573–4. Additional Declarations No competing interests reported. Supplementary Files Videa1.avi Videa2.avi Video3.avi Cite Share Download PDF Status: Published Journal Publication published 27 Oct, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 11 Sep, 2025 Reviews received at journal 07 Sep, 2025 Reviews received at journal 30 Aug, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 24 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviewers agreed at journal 22 Aug, 2025 Reviewers agreed at journal 20 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers invited by journal 17 Aug, 2025 Editor assigned by journal 01 Aug, 2025 Submission checks completed at journal 01 Aug, 2025 First submitted to journal 16 Jul, 2025 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-7144652","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":505498642,"identity":"a1c67179-8354-4be3-b0b0-ca997209633d","order_by":0,"name":"Xin Zhao","email":"","orcid":"","institution":"Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Zhao","suffix":""},{"id":505498643,"identity":"2f79977d-ffda-44d3-b2d1-f6cc113bdb39","order_by":1,"name":"Jiaxin Xu","email":"","orcid":"","institution":"Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Jiaxin","middleName":"","lastName":"Xu","suffix":""},{"id":505498644,"identity":"ea35f50c-ebc8-48d4-b552-35871776687a","order_by":2,"name":"Zhizhong Yu","email":"","orcid":"","institution":"Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Zhizhong","middleName":"","lastName":"Yu","suffix":""},{"id":505498645,"identity":"ad70f360-5437-41f7-874c-27f640e608e9","order_by":3,"name":"Dan Xu","email":"","orcid":"","institution":"Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Xu","suffix":""},{"id":505498646,"identity":"684a5882-5d9b-4527-8c35-dd1bfa99a7d8","order_by":4,"name":"Hong Liu","email":"","orcid":"","institution":"Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Liu","suffix":""},{"id":505498647,"identity":"49497539-0684-46f5-b8c4-43ad2dc49743","order_by":5,"name":"Jiancheng Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYDACCYYEZhDNxt7Y+OADSVr4eA43G84gUgsDWIucRHqbNAcxOuRnNzz8XFBxx65N8mGDNAODnZxuAwEtjHMOJEvPOPMsuU06scG4gCHZ2OwAAS3MEglpzLxth5PZgFqSZzAcSNxGSAsbWMs/oBbJgw2HeYjRwgPW0nDYjk2CsbGZKC0SEgnJ0jzHDiew8SQ2M84wIMIv8jNyEj/z1By2l28//vzHhwo7OYJagE5LAJGJDWCOAUHlIMAONtWeKLWjYBSMglEwMgEAekk/9et3ITYAAAAASUVORK5CYII=","orcid":"","institution":"Huazhong University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Jiancheng","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-07-17 04:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7144652/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7144652/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-025-01021-z","type":"published","date":"2025-10-27T15:57:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89982149,"identity":"aff5fd0b-346b-4cc9-8781-ee4b9d52ea94","added_by":"auto","created_at":"2025-08-27 06:28:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6843453,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Scattered filling defects are observed in the main pulmonary arteries and their branches, predominantly in the right pulmonary artery. (B) Placement of an inferior vena cava filter.\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-7144652/v1/69cbf0dd3deaa7b8901e0904.png"},{"id":89982148,"identity":"19341acd-d1c3-4d7c-b0cd-f691f9ac97fb","added_by":"auto","created_at":"2025-08-27 06:28:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3849694,"visible":true,"origin":"","legend":"\u003cp\u003eThe position of the venoarterial extracorporeal membrane oxygenation (VA-ECMO) drainage cannula is confirmed by chest X-ray (A) and transthoracic echocardiography (TTE) (B).\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-7144652/v1/2f2eb29703ad91261ddc2ef7.png"},{"id":95039852,"identity":"c48a95a4-027f-42f8-ba3b-ab0ecd427318","added_by":"auto","created_at":"2025-11-03 16:04:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11280735,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7144652/v1/8d66434f-35fb-4d96-987f-f96e77b36e86.pdf"},{"id":89982164,"identity":"d6089bb7-7d3d-4e8f-b492-0bca65f30157","added_by":"auto","created_at":"2025-08-27 06:28:14","extension":"avi","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26258432,"visible":true,"origin":"","legend":"","description":"","filename":"Videa1.avi","url":"https://assets-eu.researchsquare.com/files/rs-7144652/v1/abd857a3320afc90a0bea991.avi"},{"id":89982158,"identity":"dae029ca-b501-432f-8972-9e90447434c9","added_by":"auto","created_at":"2025-08-27 06:28:14","extension":"avi","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14865920,"visible":true,"origin":"","legend":"","description":"","filename":"Videa2.avi","url":"https://assets-eu.researchsquare.com/files/rs-7144652/v1/4cf3e9084129f11fbb04bdff.avi"},{"id":89982151,"identity":"a73531df-272a-4b23-8401-e5d9e18ef9bd","added_by":"auto","created_at":"2025-08-27 06:28:14","extension":"avi","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":6968804,"visible":true,"origin":"","legend":"","description":"","filename":"Video3.avi","url":"https://assets-eu.researchsquare.com/files/rs-7144652/v1/4ea39ec8e4e02355573f5805.avi"}],"financialInterests":"No competing interests reported.","formattedTitle":"Inserting a VA-ECMO Drainage Cannula into the Inferior Vena Cava through the Internal Jugular Vein in a Patient with an IVC Filter","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn addition to standard anticoagulation therapy [1], the placement of inferior vena cava (IVC) filters is a well-established intervention that effectively prevents further embolization of deep vein thrombosis (DVT) and reduces the risk of pulmonary embolism (PE), thereby significantly lowering the recurrence rate of this potentially life-threatening complication [2, 3]. However, when venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is required in patients with an existing IVC filter, careful selection of the cannulation route becomes essential. This case report describes a patient with acute massive PE caused by thrombus detachment from lower extremity DVT secondary to thrombophilia, complicated by obstructive shock. The patient was urgently initiated on VA-ECMO. Due to the presence of a pre-existing IVC filter, internal jugular vein cannulation was selected for venous drainage, with the catheter traversing the superior vena cava and right atrium to reach the inferior vena cava.\u003c/p\u003e"},{"header":"Presentation of case","content":"\u003cp\u003eAn 18-year-old male patient, a Moroccan international student in China, presented to the emergency department of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, with a chief complaint of persistent upper abdominal pain for one week that had worsened over the past 24 hours, accompanied by dyspnea, nausea, and vomiting. On physical examination, he exhibited signs of acute illness, drowsiness, tachypnea (respiratory rate (RR): 40 breaths/min), severe hypoxemia (peripheral oxygen saturation (SpO₂): 80%), hypotension (blood pressure (BP): 80/30 mmHg), tachycardia (heart rate (HR): 120 beats/min), arrhythmia with frequent premature beats, and peripheral cyanosis. Immediate intravenous infusion of vasoactive agents was initiated to stabilize hemodynamics. Transthoracic echocardiography (TTE) revealed pulmonary artery dilation with severe pulmonary hypertension, right ventricular (RV) enlargement, diffuse RV hypokinesis, severe tricuspid regurgitation, a high-density intraluminal shadow at the origin of the left pulmonary artery, and dilated inferior vena cava. Lower limb ultrasound demonstrated iliac vein thrombosis. No significant abnormalities were identified on head, chest, and abdominal CT scans. Subsequently, emergency computed tomographic angiography (CTA) of the entire aorta and pulmonary arteries was performed, revealing multiple filling defects involving both main pulmonary arteries and their branches, more prominently on the right side, consistent with acute PE. An urgent consultation with the interventional radiology team was requested immediately.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The patient’s condition deteriorated rapidly, with progressive decline in consciousness, SpO₂, and BP. His Pulmonary Embolism Severity Index (PESI) score was calculated as 180, corresponding to risk class V, indicating an extremely high mortality risk. Emergency interventions including pulmonary artery thrombectomy, inferior vena cava filter placement, iliac vein thrombectomy, pulmonary angiography, and inferior vena cava angiography were promptly carried out. Angiographic findings confirmed patent inferior vena cava with unobstructed flow; however, scattered filling defects were observed in the main pulmonary arteries and their branches, predominantly on the right side, with significantly impaired blood flow (Fig 1A). An umbrella-type inferior vena cava filter was urgently deployed (Fig 1B), followed by pulmonary artery thrombectomy. Post-procedural angiography demonstrated a marked reduction in filling defects within the main right pulmonary artery and some of its branches, along with improved blood flow velocity.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Due to the patient’s extremely critical condition, he was urgently transferred to the intensive care unit (ICU) for further life-supporting interventions following the completion of interventional procedures. Upon ICU admission, the patient was in a state of shallow coma with tachypnea. Cardiopulmonary monitoring revealed a HR of 133 beats/min, RR of 27 breaths/min, BP of 131/71 mmHg (maintained with norepinephrine infusion at 0.17 μg/kg/min), and SpO₂ of 68%. Physical examination showed cyanosis of the lips, coarse bilateral lung sounds on auscultation, and arrhythmia. Emergency endotracheal intubation was performed, and invasive mechanical ventilation was initiated using synchronized intermittent mandatory ventilation (SIMV) mode (FiO₂ 1.0, tidal volume 500 mL, RR 24 breaths/min, PEEP 8 cmH₂O). Concurrently, analgesia and sedation were administered, and the norepinephrine dose was increased to 0.3 μg/kg/min to support hemodynamics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInitial arterial blood gas analysis demonstrated severe acidosis: pH 6.95, PaO₂ 71 mmHg, PaCO₂ 67 mmHg, lactate 9.4 mmol/L, base excess –18.3 mmol/L. Intravenous administration of 5% sodium bicarbonate was promptly initiated to correct metabolic acidosis, resulting in an improvement of SpO₂ to approximately 90%. However, one hour later, SpO₂ declined gradually to 84%, and BP decreased to 80/60 mmHg despite ongoing norepinephrine infusion at 0.3 μg/kg/min. Repeat arterial blood gas analysis showed: pH 7.23, PaO₂ 50 mmHg, PaCO₂ 62 mmHg, lactate 6.7 mmol/L, HCO₃⁻ 26.0 mmol/L, FiO₂ 1.0. TTE revealed RV dilation with a right ventricle/left ventricle ratio greater than 1 (Video 1, Video 2). Considering concomitant hematuria, prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT), and the high risk of systemic bleeding associated with thrombolytic therapy, the decision was made—after obtaining informed consent from the patient’s family—to initiate emergency VA-ECMO.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Ultrasound-guided percutaneous cannulation was performed, including placement of a 22-French right internal jugular vein drainage catheter and a 19-French femoral artery return catheter. The tip of the drainage catheter was positioned above the hepatic vein confluence within the inferior vena cava. Real-time ultrasound guidance was used during insertion, and final catheter positioning was confirmed by chest X-ray and bedside echocardiography (Fig 2, Video 3). The initial ECMO flow was set at 3 L/m²/min. During VA-ECMO support, anticoagulation with unfractionated heparin was administered to maintain APTT between 50–60 seconds, while norepinephrine was continuously infused to maintain mean arterial pressure above 65 mmHg.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Following initiation of VA-ECMO, the patient’s clinical status gradually improved. Endotracheal extubation was performed on day 3 post-ICU admission, followed by transition to high-flow nasal cannula oxygen therapy. From day 3 to day 5, as cardiac function and hemodynamic parameters stabilized, ECMO support was progressively weaned and ultimately discontinued. On day 7, the patient was switched to low-flow nasal oxygen with stable vital signs. He was transferred to the Department of Respiratory Medicine on day 9 and discharged uneventfully on day 11. Subsequent genetic testing via next-generation sequencing identified a mutation in the F2 gene, confirming the diagnosis of hereditary thrombophilia. Lifelong oral anticoagulation with rivaroxaban was prescribed. Follow-up evaluations indicated that the patient had successfully resumed normal daily activities.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThrombophilia refers to a hereditary or acquired condition characterized by defects in anticoagulant proteins, coagulation factors, or fibrinolytic proteins, or the presence of acquired risk factors that predispose individuals to thromboembolic events, primarily venous thromboembolism (VTE) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Based on clinical manifestations, physical findings, and laboratory evidence, thrombophilia is generally categorized into two major types: hereditary and acquired. Among hereditary forms, the prothrombin gene (F2) G20210A mutation ranks as the second most common genetic risk factor after factor V Leiden mutation. This mutation contributes to a hypercoagulable state by increasing plasma prothrombin levels by approximately 30% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The prevalence of this mutation is approximately 2\u0026ndash;4% in European and American populations, whereas it is exceedingly rare (\u0026lt;\u0026thinsp;0.5%) among Asian and African populations.\u003csup\u003e4\u003c/sup\u003e More than 10% of the general population carries at least one identifiable hereditary thrombophilia variant, and such conditions are responsible for at least one-third of all VTE cases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, approximately one-third of patients with DVT will develop concurrent PE [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe global annual incidence of PE ranges from 39 to 115 per 100,000 individuals [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Massive PE accounts for approximately 4.5\u0026ndash;10% of all PE cases and is associated with mortality rates exceeding 50% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In such critically ill patients, VA-ECMO can serve as a valuable hemodynamic support strategy. Although VA-ECMO does not directly remove pulmonary arterial thrombi, it alleviates RV preload, reduces RV dilation, and enhances right coronary perfusion, thereby providing a critical window for thrombus resolution [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn patients requiring venovenous ECMO (VV-ECMO) who have previously undergone inferior vena cava (IVC) filter placement, the use of double-lumen catheters via the internal jugular vein represents a preferable alternative. Ngoc Minh Le et al. reported a case involving a patient with COVID-19 and concomitant DVT who successfully underwent VV-ECMO following IVC filter implantation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Due to obstruction caused by the filter, femoral vein cannulation was not feasible, prompting successful insertion of a double-lumen jugular catheter. However, in patients undergoing VV-ECMO or VA-ECMO with pre-existing IVC filters, conventional peripheral cannulation via the femoral vein-femoral artery route presents significant technical challenges and risks [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Dhaval Pau et al. described a case of severe pneumonia-induced respiratory failure requiring VV-ECMO in a patient with a prior IVC filter. Under transesophageal echocardiography (TEE) and fluoroscopic guidance, both jugular and femoral vein access were achieved without filter displacement [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, a report from Nanjing Drum Tower Hospital, Southeast University, documented a case of massive PE treated with thrombectomy and IVC filter placement followed by VA-ECMO during cardiac arrest. During extracorporeal cardiopulmonary resuscitation, femoral vein cannulation through the IVC filter was technically feasible but resulted in filter migration, tilting, and structural deformation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our case, the patient had an umbrella-type IVC filter and confirmed lower extremity DVT, making femoral vein cannulation highly risky. Therefore, an alternative cannulation strategy was urgently required. Our team successfully performed TTE-guided placement of a single-lumen drainage catheter via the right internal jugular vein, with the tip positioned within the inferior vena cava, combined with femoral artery return cannulation for VA-ECMO support. This approach enabled effective management of massive PE without compromising filter integrity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFor patients with pre-existing IVC filters, internal jugular vein cannulation for VA-ECMO drainage via placement of a single-lumen catheter into the inferior vena cava is technically feasible.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all nurses, attending physicians, and healthcare staff from for their dedicated support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ. C. Z. and X. Z. conceptualized the case report, conducted the literature review, drafted the initial manuscript, and critically reviewed and revised the manuscript. X. Z., J. X. X., Z. Z. Y., and D. X. were responsible for data acquisition and figure editing. H. L. contributed expert input during the critical review and revision of the manuscript. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient consented to the publishing of all images, clinical data, and other data included in the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKhorana AA, Mackman N, Falanga A, Pabinger I, Noble S, Ageno W, et al. Cancer-associated venous thromboembolism. Nat Rev Dis Primers. 2022;8(1):11.\u003c/li\u003e\n \u003cli\u003eMartinez LC, Mccurdy CM, Maldonado SM, Lee LS. Current management of acute pulmonary embolism. Ann Thorac Cardiovasc Surg. 2020;26(2):65\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eDuffett L. Deep venous thrombosis. Ann Intern Med. 2022;175(9):ITC129\u0026ndash;44.\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;15(6):e249195.\u003c/li\u003e\n \u003cli\u003eStevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, et al. Antithrombotic therapy for vte disease: second update of the chest guideline and expert panel report. Chest. 2021;160(6):e545\u0026ndash;608.\u003c/li\u003e\n \u003cli\u003e. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the prepic (prevention du risque d\u0026apos;embolie pulmonaire par interruption cave) randomized study. Circulation. 2005;112(3):416\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eLorusso R, Shekar K, Maclaren G, Schmidt M, Pellegrino V, Meyns B, et al. Elso interim guidelines for venoarterial extracorporeal membrane oxygenation in adult cardiac patients. Asaio J. 2021;67(8):827\u0026ndash;44.\u003c/li\u003e\n \u003cli\u003eWendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res. 2016;118(9):1340\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eMcguire WC, Sullivan L, Odish MF, Desai B, Morris TA, Fernandes TM. Management strategies for acute pulmonary embolism in the icu. Chest. 2024;166(6):1532\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eGould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of vte in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e227S\u0026ndash;e277S.\u003c/li\u003e\n \u003cli\u003eZhang L, Cao H, Chen Y, Jiao G. Risk factors for venous thromboembolism following spinal surgery: a meta-analysis. Medicine (Baltimore). 2020;99(29):e20954.\u003c/li\u003e\n \u003cli\u003eEssien EO, Rali P, Mathai SC. Pulmonary embolism. Med Clin North Am. 2019;103(3):549\u0026ndash;64.\u003c/li\u003e\n \u003cli\u003eBauer KA. The thrombophilias: well-defined risk factors with uncertain therapeutic implications. Ann Intern Med. 2001;135(5):367\u0026ndash;73.\u003c/li\u003e\n \u003cli\u003eConnors JM. Thrombophilia testing and venous thrombosis. N Engl J Med. 2017;377(12):1177\u0026ndash;87.\u003c/li\u003e\n \u003cli\u003eAssmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, et al. Use of extracorporeal circulation (ecls/ecmo) for cardiac and circulatory failure -a clinical practice guideline level 3. Esc Heart Fail. 2022;9(1):506\u0026ndash;18.\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;44(9):1573\u0026ndash;4.\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":"Inferior vena cava filter, VA-ECMO, Obstructive shock, VTE","lastPublishedDoi":"10.21203/rs.3.rs-7144652/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7144652/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is a critical treatment for patients with massive pulmonary embolism (PE) complicated by refractory cardiogenic shock. In this case, an inferior vena cava (IVC) filter and iliac vein thrombosis posed a risk of filter migration with conventional femoral venous access, necessitating an alternative drainage approach. We treated an 18-year-old male with hereditary thrombophilia due to a prothrombin gene (F2) mutation who presented with acute massive PE and obstructive shock. Following emergency pulmonary artery thrombectomy and IVC filter placement, VA-ECMO was initiated using right internal jugular vein cannulation for venous drainage and femoral artery cannulation for arterial return. Hemodynamic stability was rapidly achieved, allowing successful weaning and decannulation within 96 hours. The patient was discharged on postoperative day 11 without neurological complications. This case demonstrates that jugular-to-IVC cannulation is a feasible and effective VA-ECMO drainage strategy for patients with existing IVC filters, avoiding mechanical complications associated with filter traversal.\u003c/p\u003e","manuscriptTitle":"Inserting a VA-ECMO Drainage Cannula into the Inferior Vena Cava through the Internal Jugular Vein in a Patient with an IVC Filter","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:28:09","doi":"10.21203/rs.3.rs-7144652/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-11T14:15:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T15:05:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-30T05:22:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T07:16:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158260292995246976309307439250245757082","date":"2025-08-24T19:59:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T05:18:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94621547265966147320384112291253105860","date":"2025-08-22T04:48:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198270241058093616589904713067438431882","date":"2025-08-20T07:23:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127892895479141170837425225832838914079","date":"2025-08-20T03:03:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-18T01:44:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-01T05:39:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-01T05:37:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2025-07-17T03:55:31+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":"420ffcbb-332b-4acf-a99b-ed561dfebbd0","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T15:59:47+00:00","versionOfRecord":{"articleIdentity":"rs-7144652","link":"https://doi.org/10.1186/s12245-025-01021-z","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2025-10-27 15:57:07","publishedOnDateReadable":"October 27th, 2025"},"versionCreatedAt":"2025-08-27 06:28:09","video":"","vorDoi":"10.1186/s12245-025-01021-z","vorDoiUrl":"https://doi.org/10.1186/s12245-025-01021-z","workflowStages":[]},"version":"v1","identity":"rs-7144652","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7144652","identity":"rs-7144652","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}