Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides crucial circulatory and respiratory support in refractory cardiogenic shock and cardiac arrest. However, peripheral VA-ECMO increases left ventricular (LV) afterload through retrograde aortic flow, leading to LV distension, impaired aortic valve opening, pulmonary congestion, and compromised myocardial recovery.

We report a 56-year-old male (BMI 30.2) with acute myocardial infarction–induced cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation (ECPR) with VA-ECMO. Conventional unloading devices were unavailable. A percutaneous transaortic catheter venting (TACV) strategy was therefore adopted via the right carotid artery. Under digital subtraction angiography and real-time ultrasound guidance, a 15Fr cannula was advanced across the aortic valve into the LV and connected to the pre-pump segment of the ECMO circuit using 3/8-inch tubing and a Y-connector. LV decompression was titrated with a Hoffman clamp and cannula position adjustment. Percutaneous coronary intervention (PCI) was performed under VA-ECMO support where a drug-coated balloon was used to treat severe stenosis in the proximal-to-mid left anterior descending artery. After TACV initiation, the LV decompression flow was maintained at 1.5–1.8 L/min, and the concurrent ECMO total flow was 3.3–3.5 L/min. Anticoagulation was achieved with unfractionated heparin sodium, targeting an activated clotting time (ACT) of 180–220 s and an activated partial thromboplastin time (APTT) of 45–60 s. During the procedure, ACT ranged from 190 to 235 s, and APTT from 63 to 65 s. During TACV, mean arterial pressure (MAP) was maintained at 60–70 mmHg, and SpO₂ ranged from 92% to 98%, indicating improved systemic perfusion.

This TACV strategy achieved rapid LV decompression and improved myocardial function. The patient returned to sinus rhythm after a single defibrillation.

Flow-controlled TACV via the carotid artery offers a feasible and pragmatic option for LV unloading during VA-ECMO when conventional devices are unavailable. This case suggests that flow-controlled TACV may serve as a pragmatic rescue strategy for LV decompression in VA-ECMO when conventional devices are unavailable. However, this approach should not be considered a routine or superior alternative to established unloading strategies.