Navigating Venoarterial Extracorporeal Membrane Oxygenation in Anorexia Nervosa: Overcoming Ultrasmall Femoral Artery Cannulation in Toxic Cardiomyopathy

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Toxic cardiomyopathy and refractory cardiogenic shock secondary to antipsychotic medication overdose in severe anorexia nervosa (n=1). Intervention: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) with rescue micropuncture-guided distal perfusion cannula placement. Primary outcome: Myocardial recovery, successful ECMO decannulation, and survival to intensive care unit discharge.

Q: What does this research mean for the field?

VA-ECMO utilizing rescue micropuncture distal perfusion cannulation can successfully support myocardial recovery in patients with severe anorexia nervosa and toxic cardiomyopathy despite ultrasmall femoral artery caliber. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Apul Mathur; Amit Mehta; Hukam Sharma; Mohit Kumar; Geetesh Mangal; P P Mathur; Aadarsh Kabra; Vijayant Solanki

doi:10.5005/jp-journals-11006-0246

October 26, 2026Indian Journal of Critical Care Case ReportOpen Access

Navigating Venoarterial Extracorporeal Membrane Oxygenation in Anorexia Nervosa: Overcoming Ultrasmall Femoral Artery Cannulation in Toxic Cardiomyopathy

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Key result

Micropuncture distal perfusion during VA-ECMO enables full myocardial recovery in severe toxic cardiomyopathy.

n=1

Why the study?

Patients with anorexia nervosa and severe malnutrition exhibit reduced arterial diameter, increased vasoreactivity, and decreased vascular compliance, creating a fragile vascular phenotype that significantly complicates large-bore vascular access required for VA-ECMO in antipsychotic-induced toxic cardiomyopathy.

Key Points

Describe cannulation and hemodynamic management strategies for venoarterial extracorporeal membrane oxygenation (VA-ECMO) in a patient with severe anorexia nervosa and antipsychotic-induced toxic cardiomyopathy.
Evaluation of a 22-year-old woman (weight 37 kg, BMI 14.5 kg/m²) presenting with refractory cardiogenic shock, lactic acidosis (11–12 mmol/L), and an ejection fraction of 10–15% following an overdose of nondialyzable antipsychotic medications.
VA-ECMO was initiated under ultrasound guidance with a 22-Fr venous cannula and a 14-Fr arterial cannula, followed by rescue placement of a 6-Fr distal perfusion cannula into the superficial femoral artery via a 21-gauge micropuncture needle.
Bedside ultrasound demonstrated severe arterial narrowing and vasospasm, showing a common femoral artery diameter of approximately 2 mm and a superficial femoral artery lumen of approximately 0.5 mm.
Maximum ECMO flows reached 2.0–2.5 L/min at 2,500–3,000 rpm, with flow limitations and circuit chattering identified as vasospasm-induced rather than hypovolemia.
As myocardial function recovered, ECMO flows were safely weaned to 1.2–1.5 L/min before successful decannulation.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

A 22-year-old woman (BMI 14.5 kg/m²) with severe anorexia nervosa, hypothyroidism, and distal renal tubular acidosis presenting with antipsychotic-induced toxic cardiomyopathy and refractory cardiogenic shock (LVEF 10–15%).

I

Intervention

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) initiated via ultrasound-guided 22-Fr venous and 14-Fr arterial cannulation, followed by rescue micropuncture-guided (21-gauge needle, 0.021-inch guidewire, 5-Fr dilator) placement of a 6-Fr distal perfusion cannula in the severely spasmed superficial femoral artery, alongside post-ECMO albumin supplementation, aggressive diuresis, high-flow nasal cannula, and bilateral pleural drains.

O

Outcome

Myocardial recovery, successful decannulation from VA-ECMO, extubation, and survival to intensive care unit discharge.hard clinical

This case report demonstrates that life-saving VA-ECMO is feasible in patients with severe anorexia nervosa and antipsychotic-induced cardiogenic shock when utilizing micropuncture-guided distal perfusion cannulation and cautious fluid management to overcome ultrasmall, vasospastic femoral arteries.

Limitations

Single-patient case report design
Lack of long-term follow-up restricting generalizability
Single-patient design
Lack of long-term follow-up

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May inform rescue cannulation strategies in malnourished VA-ECMO candidates; hypothesis-generating and requires prospective validation.

Abstract

hypothyroidism, and underlying distal renal tubular acidosis presented after ingestion of multiple antipsychotic medications.On arrival, she was conscious and hemodynamically stable.However, IntroductIonToxic cardiomyopathy induced by antipsychotic medications is an uncommon but potentially reversible cause of cardiogenic shock.Many atypical antipsychotics possess high lipid solubility, extensive protein binding, and large volumes of distribution, rendering them largely nondialyzable.1,2 In severe cases complicated by refractory shock and metabolic acidosis, extracorporeal membrane oxygenation (ECMO) remains the only definitive supportive therapy until myocardial recovery occurs.Patients with anorexia nervosa and severe malnutrition exhibit profound cardiovascular and vascular adaptations, including reduced arterial diameter, increased vasoreactivity, decreased vascular compliance, and impaired autonomic regulation.3,4 These features create a fragile vascular phenotype that significantly complicates large-bore vascular access required for venoarterial extracorporeal membrane oxygenation (VA-ECMO).We describe a case of toxic cardiomyopathy in a patient with severe anorexia nervosa in whom ultrasmall femoral artery caliber and profound vasospasm necessitated innovative cannulation strategies to successfully deliver lifesaving ECMO support. case descrIptIonA 22-year-old woman weighing 37 kg [body mass index (BMI) 14.5 kg/m²] with a history of severe malnutrition, poor oral intake, 1,2,5,

Discussion

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Cite This Study

Mathur et al. (2026) conducted a case report in Toxic cardiomyopathy and refractory cardiogenic shock secondary to antipsychotic medication overdose in severe anorexia nervosa (n=1). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) with rescue micropuncture-guided distal perfusion cannula placement was evaluated on Myocardial recovery, successful ECMO decannulation, and survival to intensive care unit discharge. VA-ECMO with rescue micropuncture distal perfusion cannulation achieved full myocardial recovery and ICU discharge in a 22-year-old woman (BMI 14.5 kg/m²) with toxic cardiomyopathy.

synapsesocial.com/papers/6aee6bb371a7594806220ad8 https://doi.org/10.5005/jp-journals-11006-0246

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Navigating Venoarterial Extracorporeal Membrane Oxygenation in Anorexia Nervosa: Overcoming Ultrasmall Femoral Artery Cannulation in Toxic Cardiomyopathy

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Navigating Venoarterial Extracorporeal Membrane Oxygenation in Anorexia Nervosa: Overcoming Ultrasmall Femoral Artery Cannulation in Toxic Cardiomyopathy

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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