Melissa is what we often refer to as a “sticky wicket”, a term from the game of cricket when the field is wet and soft making the bounce of the ball very unpredictable. In Melissa’s case it suggests that her condition must be managed delicately: She is bleeding, but needs anticoagulation; she needs surgery, but is unstable with risk of decompensation from additional emboli. Even though she has an IVC filter in place to prevent a large embolus, multiple small emboli could plug the little remaining pulmonary blood flow she has. Review of the entire CT suggested she had clots occluding as much as 85% of her proximal pulmonary branches. And the IVC filter complicates ECMO cannulation considerably. She is certainly a candidate for ECMO, but what and when and how remain in question. There are a number of possible approaches that could be right, but here is how Melissa was managed.

She did not have an immediate need for ECMO as long as she could be anticoagulated and stabilized. She was not a candidate for TPA, but if the source of the clot in her leg was fresh, it would lyse on its own with heparin and time. We explained the situation and our plan to the patient and her family, and got consent for ECMO in an emergency. An ECMO circuit was primed and kept in the ICU near her room. Her bleeding continued, but not measurably faster on heparin, and she required several transfusions. She had periodic CT scans showing gradual resolution of the clots in the lungs. After about three weeks of this conservative management, much of the pulmonary clots had lysed. She was taken to the OR for her hysterectomy, with an ECMO circuit and team on standby, and placed in a fluoroscopy capable room and OR table. She had a preoperative RIJ cordis placed for RA drainage access if needed, and her groins were prepped into the field. Fortunately, the procedure went without complications, she was converted to Coumadin and discharged to home.