Chest compression-related fatal internal mammary artery injuries manifesting after venoarterial extracorporeal membrane oxygenation: a case series

Journal of Medical Case Reports, Nov 2017

Cardiopulmonary resuscitation-related bleeding, especially internal mammary artery injuries, can become life-threatening complications after initiating venoarterial extracorporeal membrane oxygenation owing to the frequent involvement of concomitant anticoagulant treatment, antiplatelet treatment, targeted temperature management, and bleeding coagulopathy. We report the cases of five patients who experienced this complication and discuss their management. We retrospectively evaluated five patients with cardiopulmonary resuscitation-related internal mammary artery injuries who were treated between February 2011 and February 2016 at our institution. All five patients were Asian men, aged 56 to 68-years old, who had received concomitant intravenously administered unfractionated heparin (3000 units) with antiplatelet therapy. Four patients received targeted temperature management. The injuries and hematomas were detected using contrast-enhanced computed tomography in all cases. Three patients were treated using transcatheter arterial embolization within 6 hours following cardiopulmonary arrest, and two were resuscitated and received appropriate treatment following early recognition of their injuries. Two patients died of hemorrhagic shock with delayed intervention. Four of the five patients had excessively prolonged activated partial thromboplastin times before their interventions. Computed tomography should be performed as soon as possible after the return of spontaneous circulation to identify injuries and consider appropriate treatments for patients who have experienced cardiac arrest. Delayed bleeding may develop after treating hypovolemic shock and relieving arterial spasms; therefore, transcatheter arterial embolization should be performed aggressively to prevent delayed bleeding even in the absence of extravasation. This approach may be superior to thoracotomy because it is less invasive, causes less bleeding, and can selectively stop arterial bleeding sooner. A 3000-unit intravenous bolus of unfractionated heparin may be redundant; heparin-free extracorporeal cardiopulmonary resuscitation may be a more appropriate alternative. Unfractionated heparin treatment can commence after the bleeding has stopped.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://jmedicalcasereports.biomedcentral.com/track/pdf/10.1186/s13256-017-1485-y?site=jmedicalcasereports.biomedcentral.com

Chest compression-related fatal internal mammary artery injuries manifesting after venoarterial extracorporeal membrane oxygenation: a case series

Yamagishi et al. Journal of Medical Case Reports Chest compression-related fatal internal mammary artery injuries manifesting after venoarterial extracorporeal membrane oxygenation: a case series Toshinobu Yamagishi 1 Masahiro Kashiura 0 Kazuhiro Sugiyama 1 Kazuha Nakamura 1 Takuto Ishida 1 Takahiro Yukawa 1 Kazuki Miyazaki 1 Takahiro Tanabe 1 Yuichi Hamabe 1 0 Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center , 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503 , Japan 1 Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital , 4-23-15 Kotobashi, Sumida-ku, Tokyo 130-8575 , Japan Background: Cardiopulmonary resuscitation-related bleeding, especially internal mammary artery injuries, can become life-threatening complications after initiating venoarterial extracorporeal membrane oxygenation owing to the frequent involvement of concomitant anticoagulant treatment, antiplatelet treatment, targeted temperature management, and bleeding coagulopathy. We report the cases of five patients who experienced this complication and discuss their management. Case presentation: We retrospectively evaluated five patients with cardiopulmonary resuscitation-related internal mammary artery injuries who were treated between February 2011 and February 2016 at our institution. All five patients were Asian men, aged 56 to 68-years old, who had received concomitant intravenously administered unfractionated heparin (3000 units) with antiplatelet therapy. Four patients received targeted temperature management. The injuries and hematomas were detected using contrast-enhanced computed tomography in all cases. Three patients were treated using transcatheter arterial embolization within 6 hours following cardiopulmonary arrest, and two were resuscitated and received appropriate treatment following early recognition of their injuries. Two patients died of hemorrhagic shock with delayed intervention. Four of the five patients had excessively prolonged activated partial thromboplastin times before their interventions. Conclusions: Computed tomography should be performed as soon as possible after the return of spontaneous circulation to identify injuries and consider appropriate treatments for patients who have experienced cardiac arrest. Delayed bleeding may develop after treating hypovolemic shock and relieving arterial spasms; therefore, transcatheter arterial embolization should be performed aggressively to prevent delayed bleeding even in the absence of extravasation. This approach may be superior to thoracotomy because it is less invasive, causes less bleeding, and can selectively stop arterial bleeding sooner. A 3000-unit intravenous bolus of unfractionated heparin may be redundant; heparin-free extracorporeal cardiopulmonary resuscitation may be a more appropriate alternative. Unfractionated heparin treatment can commence after the bleeding has stopped. Extracorporeal membrane oxygenation; Cardiopulmonary resuscitation; Mammary arteries; Hemorrhagic shock; Therapeutic embolization; Heparin; Platelet aggregation inhibitors; Induced hypothermia Background Chest compressions for cardiopulmonary resuscitation (CPR) were emphasized in the 2010 American Heart Association CPR guidelines [ 1 ]. However, CPR-related bleeding complications are not uncommon [ 2–4 ], and CPR-related fractures have been observed more frequently since 2010 [ 5, 6 ]. Furthermore, CPR-related bleeding, particularly internal mammary artery (IMA) injuries, can become life-threatening in patients who undergo extracorporeal cardiopulmonary resuscitation (ECPR) because concomitant anticoagulant treatment [7], antiplatelet treatment, targeted temperature management [ 8 ], and bleeding coagulopathy [ 9 ] are often involved. We investigated five patients with CPR-related IMA injuries that occurred after they had undergone venoarterial extracorporeal membrane oxygenation (VA-ECMO). Case presentations We retrospectively evaluated the medical records of patients with cardiac arrest who underwent VA-ECMO between February 2011 and February 2016 at our institution. Of the 129 patients identified, five experienced CPR-related IMA injuries. Four of these patients underwent ECPR and one underwent VA-ECMO for cardiogenic shock after the return of spontaneous circulation (ROSC). All five patients were Asian men who had received 3000 units of intravenously administered unfractionated heparin with concomitant antiplatelet therapy for suspected acute coronary syndrome. Four of the five patients underwent targeted temperature management (the exception being Patient 3). Contrastenhanced computed tomography (CT) revealed CPRrelated chest bleeding complications in all cases, for example, IMA injuries, intercostal artery (ICA) injuries, mediastinum hematoma, and hemothorax. Case 1 A 65-year-old Asian man had a history of myocardial infarction and atrial fibrillation, and was receiving dual antiplatele (...truncated)


This is a preview of a remote PDF: https://jmedicalcasereports.biomedcentral.com/track/pdf/10.1186/s13256-017-1485-y?site=jmedicalcasereports.biomedcentral.com

Toshinobu Yamagishi, Masahiro Kashiura, Kazuhiro Sugiyama, Kazuha Nakamura, Takuto Ishida, Takahiro Yukawa, Kazuki Miyazaki, Takahiro Tanabe, Yuichi Hamabe. Chest compression-related fatal internal mammary artery injuries manifesting after venoarterial extracorporeal membrane oxygenation: a case series, Journal of Medical Case Reports, 2017, pp. 318, DOI: 10.1186/s13256-017-1485-y