Massive pulmonary embolism: embolectomy or extracorporeal membrane oxygenation?

Can VA-ECMO Be Used as an Adequate Treatment in Massive Pulmonary Embolism?

Introduction: Massive acute pulmonary embolism (MAPE) with obstructive cardiogenic shock is associated with a mortality rate of more than 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used in refractory cardiogenic shock with very good results. In MAPE, although it is currently recommended as part of initial resuscitation, it is not yet considered a stand-alone therapy. Material and Methods: All patients with MAPE requiring the establishment of VA-ECMO and admitted to our tertiary intensive care unit were analysed over a period of 10 years. The characteristics of these patients, before, during and after ECMO were extracted and analysed. Results: A total of 36 patients were included in the present retrospective study. Overall survival was 64%. In the majority of cases, the haemodynamic and respiratory status of the patient improved significantly within the first 24 h on ECMO. The 30-day survival significantly increased when ECMO was used as stand-alone therapy (odds ratio (OR) 15.58, 95% confidence interval (CI) 2.65–91.57, p = 0.002). Nevertheless, when ECMO was implanted following the failure of thrombolysis, the bleeding complications were major (17 (100%) vs. 1 (5.3%) patients, p < 0.001) and the 30-day mortality increased significantly (OR 0.11, 95% CI 0.022–0.520, p = 0.006). Conclusions: The present retrospective study is certainly one of the most important in terms of the number of patients with MAPE and shock treated with VA-ECMO. This short-term mechanical circulatory support, used as a stand-alone therapy in MAPE, allows for the optimal stabilisation of patients.

Massive pulmonary embolism in a patient with nephrotic syndrome and single lung

We present a novel case of a patient with nephrotic syndrome and previous left pneumonectomy who had a massive pulmonary embolism of his remnant right pulmonary artery. He underwent surgical embolectomy and veno-arterial extracorporeal membrane oxygenation (ECMO). Early embolectomy using retrograde pulmonary perfusion and post-operative ECMO helped the patient survive this catastrophic event.

Surgical Pulmonary Embolectomy With No Systemic Anticoagulation for Patient With Recent Stroke

We present the successful use of surgical embolectomy (SE) without systemic anticoagulation to treat a complicated case of pulmonary embolism. The patient presented with an embolic cerebrovascular accident and subsequently developed a massive pulmonary embolism. Because of the risk of hemorrhagic transformation, the decision was made to proceed with emergent SE on venoarterial extracorporeal membrane oxygenation support without anticoagulation. The surgery was performed without complication. The potential to perform SE without anticoagulation could potentially decrease the incidence of surgical bleeding and make SE a therapeutic option for patients with contraindications to anticoagulation. Further research is needed to substantiate the efficacy of this treatment strategy.