C52-40 Successful Veno-Venous ECMO Support Using Dual Inferior Venous Cannulation in a Patient With Massive Pulmonary Embolism and Refractory Hypoxemia

Abstract Introduction Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a rescue therapy for severerespiratory failure unresponsive to mechanical ventilation. Conventional cannulationconfigurations include femoral-jugular or dual-lumen right internal jugular approaches,optimized to prevent recirculation. Reports of successful VV ECMO using dual inferiorcannulation are rare. We describe a case of refractory hypoxemia from massive pulmonaryembolism (PE) managed with VV ECMO utilizing two inferior venous cannulas projecting alongthe right mediastinum and terminating near the cavoatrial junction. Case Report A 29-year-old man with human immunodeficiency virus (HIV) infection (CD4 88 cells/µL, viralload 9,800 copies/mL) and poor antiretroviral adherence presented with progressive dyspnea andsevere hypoxemia. On arrival, oxygen saturation was 71% on room air and remained 80%despite high-flow nasal cannula, bilevel positive airway pressure, and mechanical ventilation.Arterial blood gas demonstrated pH 6.98 and partial pressure of carbon dioxide (PaCO2) 96 mmHg. Chest imaging revealed a large left pleural effusion with compressive atelectasis.Given refractory hypoxemia, VV ECMO was initiated emergently. Both venous cannulas wereinserted via inferior access sites and visualized coursing along the right mediastinum,terminating near the cavoatrial junction. This atypical configuration provided adequate flow andoxygenation without recirculation. Subsequent computed tomography angiography confirmed amassive PE. The patient underwent catheter-directed thrombectomy while on ECMO support. Hewas successfully decannulated after 48 hours, extubated shortly thereafter, and discharged onroom air with apixaban and resumed antiretroviral therapy. Discussion This case demonstrates the feasibility and effectiveness of dual inferior venous cannulation forVV ECMO when standard access is unavailable or time-limited. Despite deviation fromconventional cannulation sites, the circuit achieved stable flows and gas exchange. Theconfiguration—both cannulas projecting through the right mediastinum with termination near thecavoatrial junction—has been rarely described. This experience supports individualizedcannulation strategies based on patient anatomy and urgency, expanding the technical flexibilityof VV ECMO deployment in critical hypoxemia. This abstract is funded by: None