Planned Venovenous-Extracorporeal Membrane Oxygenation as a Bridge to Orthotopic Liver Transplant Performed for Very Severe Hepatopulmonary Syndrome: A Case Report.

Concerns related to poor oxygenation in patients with severe hepatopulmonary syndrome (HPS) may be prohibitive when considering their candidacy for liver transplantation. Extracorporeal membrane oxygenation (ECMO) has been utilized in only a few case reports as a bridge to liver transplant in patients with severe respiratory failure. We report a case of a 66-year-old man with cirrhosis and very severe (arterial oxygen pressure (PaO2) < 50 mmHg) hepatopulmonary syndrome who underwent an orthotopic liver transplant with the planned use of venovenous-ECMO. Pre-transplant echocardiography demonstrated a small-trivial patent foramen ovale (PFO) but following the resolution of hepatopulmonary shunting after liver transplantation, the PFO size enlarged and contributed to a thromboembolic stroke. We conclude that well-selected patients with HPS could benefit from the use of planned venovenous-ECMO and that a small-trivial PFO seen in a patient with HPS may warrant intervention prior to transplantation.

Adventitial Cystic Disease of the Popliteal Artery Contributing to Supera Stent Fracture.

A 60-year-old male presented with complaints of a non-healing wound on his right shin. Initial angiography showed a 100% occlusion of the right superficial femoral artery thought to be thrombotic in nature; he was treated with percutaneous transluminal angioplasty and stenting. Three weeks later, he presented with continuing symptoms of claudication. Angiography revealed stent fracture. Careful review of his prior angiogram was consistent with adventitial cystic disease of the popliteal artery as the cause of the popliteal artery occlusion. He was then referred for femoral-popliteal bypass.

Percutaneous Biventricular Mechanical Circulatory Support With Impella CP and Protek Duo Plus TandemHeart.

This is the first reported case of full biventricular mechanical circulatory support with the combination of Impella and Protek Duo, which is a dual-lumen cannula inserted via the right internal jugular vein, with its proximal inflow lumen positioned in the right atrium and distal lumen positioned in the main pulmonary artery. These lumens are connected with the paracorporeal TandemHeart pump allowing flows up to 5 L/min. The alternative percutaneous option for right ventricular support is the Impella RP (Abiomed), which has to be placed in the femoral vein, preventing ambulation. The axillary and internal jugular vein positions for devices are probably less prone to infection compared to the femoral area. The combination of an Impella inserted via the axillary artery with the Protek Duo is a viable option, allowing ambulation while providing biventricular support.