An Unusual Etiology of Shock after ECMO Decannulation

Finalist case in the ACCIS 2023 Madrid course We report the case of a 53-year-old male patient who required venoarterial extracorporeal membrane oxygenation (VA-ECMO) after a refractory cardiac arrest due to a ventricular fibrillation secondary to an anterolateral myocardial infarction. The cannulation was performed with a 25-Fr × 55 cm drain (right femoral vein) and a 17-Fr × 15 cm return (left common femoral artery). An intra-aortic balloon pump (IABP) was inserted through the right femoral artery (7-Fr). After stabilization, both the VA-ECMO and IABP were retrieved. The arterial insertion points were sealed with a Perclose ProGlide (Abbott, United States) system and the venous site with manual compression. Shortly afterward, the patient developed shock accompanied by hypoperfusion in the right leg (indicated by near-infrared spectroscopy readings of 17% in the right leg vs 59% in the left leg). No changes were evident on electrocardiography, echocardiography, or coronary angiography. The arterial pressure waveform analysis revealed high cardiac output, increased central venous pressure, and a low systemic vascular resistance index. Computed tomography angiography revealed a high-flow arteriovenous fistula between the right femoral vein and artery (figure 1; red arrow shows a tubular communication between the 2 vessels). To assess the hemodynamic impact of the...