29Double acute compartment syndrome in an extracorporeal membrane oxygenation (ECMO) assisted patient

Abstract

A 68-year-old man was transferred to our hospital with chest pain and diagnosis of established anterior myocardial infarction. Catheterism confirmed proximal anterior descendent artery occlusion and no-reflow phenomenon was observed in spite of implantation of a drug-eluting stent. Immediately after revascularization the patient suffered a cardiac arrest requiring advanced cardiopulmonary resuscitation and, after recovery of spontaneous circulation, vasoactive drugs and circulatory support with an intraaortic balloon pump. Despite of increasing dose of ionotropes, his haemodynamic worsened and a venoarterial extracorporeal membrane oxygenation (ECMO) was finally implanted. Left femoral artery was cannulated by arterial dissection with a 21 F cannula and a 16 F cannula was inserted in left femoral vein. A reperfusion distal cannula was added to optimize distal perfusion. Some hours after ECMO implantation a massive bleeding of the cannulation point required reintervention and countless sutures on the bled were necessary. Marked hemodinamical improvement was achieved with circulatory support but the leg progressively developed significant tense oedema and ischemic signs. Acute compartment syndrome related to venous system extensive sutures was confirmed by eco Doppler. Left leg fasciotomy was performed and ECMO cannulas were switched. Venous cannula was inserted in right femoral vein and arterial cannula in right axilar artery through a dacron patch. Important bleeding of the axillary artery occurred during the procedure. Immediatly after surgery right arm started to develop oedema, and two hours later, it was swollen and full of phlyctenas. With the diagnose of a new acute compartment syndrome the patient was reoperated to review anastomosis, finding an extensive bleeding that compressed arm vascular system. Since then, given the refractory situation, limiting therapeutic effort was decided and comfort meassures were provided until the patient died. Bleeding and thrombotic events are one of Achilles heel of assist devices and hemostasis balance is not easy in this patients. In our case, bleeding complication progressed to acute compartment syndrome twice. Ischemial limb is diagnosed even in 18% of patients with femoral access ECMO, but acute compartment syndrome is an infrequent life-threatening complication. Acute compartment syndrome related to ECMO has been previously described, but, in our acknowledge, this is the first report of repetitive compartment syndrome in two different limbs in the same patient.