Abstract Introduction The management of diffuse alveolar hemorrhage (DAH) secondary to granulomatosis with polyangiitis (GPA) is complex, often requiring aggressive immunosuppression. In cases of fulminant respiratory failure, veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be a life-saving intervention. We report a challenging case of a patient with GPA-induced DAH who was successfully supported with VV-ECMO, despite high levels of immunosuppression and the relative contraindication for standard anticoagulation. Case A 55 year old male with rheumatoid arthritis presented to an outside hospital with fever, epistaxis, dyspnea and cough for two weeks. Treated initially as sinusitis with intravenous antibiotics, the patient quickly deteriorated into multiorgan failure requiring intubation and hemodialysis. Workup was significant for c-ANCA 1:640 and PR3 +. Bronchoscopy revealed progressive bloody serial aliquots, consistent with DAH. He was diagnosed with severe ARDS with DAH from GPA. He was treated with pulse dose steroids, plasmapheresis, IVIG and cyclophosphamide. Despite the aggressive management, he continued to progress with escalating ventilator requirements, refractory hypoxia and poor lung mechanics risking ventilator-induced lung injury. He was cannulated for VV-ECMO. His course was complicated by continued alveolar hemorrhage, gastrointestinal bleeding and coagulopathy, requiring multiple transfusions. He was on ECMO for 47 days, mostly without any anticoagulation. His flows were maintained high in light of no anticoagulation. He did not require any oxygenator changes during his ECMO run. His lungs slowly improved and eventually was decannulated from ECMO. He was discharged to rehab on hospital day 81, on trach collar undergoing capping trials and off dialysis. Discussion Anticoagulation management in ECMO is a balance between bleeding and thrombosis. There is growing evidence that multifactorial coagulopathy develops during support with extracorporeal assist devices (2). An individualized approach is required for each patient in terms of assessment of the aforementioned balance. In our patient, bleeding far outweighed thrombosis so we had to forego anticoagulation entirely for almost the duration of his ECMO treatment, making this VV-ECMO run one of the longest without anticoagulation to our knowledge. This case displays that modern ECMO technology allows for lower anticoagulation (1), and raises the question of using no anticoagulation in specific, complex cases. References 1. Abrams D et al. ASAIO Journal. 2015; 61(2): 216-218. 2. Jung C et al. Anticoagulation in venovenous extracorporeal membrane oxygenation. Front. Med. 2025. 12:1530411. Doi: 10.3389/fmed.2025.1530411 This abstract is funded by: None
Mcgee et al. (Fri,) studied this question.