Presentations

Abstract

Introduction:

Massive pulmonary embolism represents the third leading cause of cardiovascular death in hospitalized patients within the United States. The management of acute high-risk PE has undergone drastic changes in the last 10 years. The primary treatment options include therapeutic anticoagulation, systemic thrombolysis, catheter-directed thrombectomy (CDT), and surgical thrombectomy. Patients with massive PE often present with complications necessitating optimization of management with existing therapies. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a novel treatment for massive PE has been reported, but limited to salvage therapy when other interventions have failed. Guidelines for ECMO use in massive PE are limited. This case report demonstrates a successful use of ECMO as support to allow a patient to undergo advanced endovascular treatment of massive PE.

Case Information:

We present a case report of a unique multidisciplinary management of massive pulmonary embolism. The patient is a 73-year-old male who presented to the emergency department with shortness of breath. He required intubation, but subsequently went into cardiac arrest. After achieving return of circulation, post-resuscitation imaging demonstrated massive bilateral pulmonary embolism (PE). The patient was not a candidate for systemic thrombolytics because of his recent cardiopulmonary resuscitation. He was critically ill, in cardiogenic shock requiring multiple pressors. Therefore, the decision was made to place the patient on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for stabilization, followed by mechanical and suction thrombectomy. These were successfully completed with improvement in the patient's hemodynamics allowing eventual ECMO decannulation.

Discussion/Clinical Findings:

This case report highlights the successful management of a critically ill patient with massive bilateral PE using a combination of VA ECMO and thrombectomy. The utilization of VA ECMO provided circulatory support while delaying the thrombectomy procedure until the patient's hemodynamic status improved. This multidisciplinary approach and endovascular intervention proved effective in treating the patient's life-threatening condition.

Conclusion:

The case presented demonstrates the efficacy of VA ECMO and delayed suction thrombectomy in managing massive bilateral PE, particularly in the presence of relative contraindications for other treatment options. This multidisciplinary approach and endovascular intervention can be considered in similar complex cases to optimize patient outcomes.