Surgical pulmonary embolectomy on VA-ECMO

Abstract

Surgical pulmonary embolectomy is a procedure that is often used to rescue patients with massive pulmonary embolism (PE) and circulatory collapse that have failed or may not be ideal candidates for other systemic and endovascular treatment modalities. This procedure typically involves a sternotomy and the use of cardiopulmonary bypass (CPB), which requires full systemic anticoagulation. Here, we report the case of a surgical pulmonary embolectomy performed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) rather than CPB to minimize systemic anticoagulation. The patient had suffered a cardiac arrest due to a saddle PE and required VA-ECMO which was complicated by a concomitant intracranial hemorrhage. The patient tolerated the surgical pulmonary embolectomy performed on VA-ECMO without procedure-related complications, and the ECMO support did not substantially complicate the technical performance of the procedure. In contrast to surgical pulmonary embolectomy performed on CPB, greater attention must be paid to volume status when performing the procedure on VA-ECMO since there is no blood reservoir. This case suggests cardiopulmonary support on ECMO as a viable strategy for surgical embolectomy in patients with unstable PEs in whom thrombolysis or full systemic anticoagulation are contraindicated.

Case Report: Resuscitation of patient with tumor-induced acute pulmonary embolism by venoarterial extracorporeal membrane oxygenation

“…Standard treatment guideline recommended that low-grade ECMO support maybe associated with a survival benefit for patients ( 9 ). For patients with contraindications to thrombolysis and anticoagulation, VA-ECMO can be used as an effective cardiopulmonary aid to provide patients the opportunity for surgical or interventional embolectomy ( 10 , 11 ). Anticoagulation therapy is not routinely recommended for tumor-induced pulmonary embolism, but it is still recommended for the prevention of secondary thrombosis ( 12 , 13 ).…”

Availability in ECMO Reduces the Failure to Rescue in Patients With Pulmonary Embolism After Major Surgery: A Nationwide Analysis of 2.4 Million Cases

“…Recent publications have yielded conflicting results with regard to VA-ECMO alone or in conjunction with embolectomy or thrombolysis for the resuscitation of patients with massive PE with or without cardiac arrest. 19 Patients with VA-ECMO who have had an embolectomy appear to have a higher survival rate and the use of VA-ECMO also seems to reduce the incidence of organ failure. 20 – 22 Recently, a post hoc analysis of patients treated with VA-ECMO due to refractory out-of-hospital cardiac arrest caused by PE found an inferior outcome compared to other cardiac arrest patients.…”

Outcomes of Surgical and Mechanical Thrombectomy in Massive Saddle Pulmonary Embolism: A National Perspective

“…Patients requiring ST are usually more critically ill and frequently have been previously mechanically ventilated, increasing the chances that they may need IMV [ 40 ]. Also, ST is often used as a last resort for patients who failed to respond or have contraindications to initial management and have contraindications to MT-i.e., patients with a higher risk of needing IMV [ 6 , 41 ].…”