Catheter directed thrombolysis combined with ECMO for massive pulmonary emboli

Abstract

This case report discusses a previously healthy young male who suffered an in hospital cardiac arrest, found to be secondary to massive pulmonary emboli (PE). This patient was not a candidate for PE dosing of tPA, but continued to have worsening cardiogenic shock and acute hypoxic respiratory failure. The decision was made to initiate venoarterial extracorporeal membrane oxygenation (VA ECMO) in combination with catheter assisted thrombolysis.With time, the sequelae of his disease process changed. Although his cardiogenic shock improved, the hypoxemia worsened, and the patient was transitioned from VA to venovenous (VV) ECMO, while managing further complications due to multiple episodes of cardiac arrest and severe coagulopathy with multiple, acute, life-threatening bleeding events.Albeit a growing field, VA and VV ECMO are less than common, individually, however this case reports outlines the even rarer event of transition from VA to VV ECMO in combination with catheter assisted thrombolysis treatment via the EKOS EndoWave Infusion Catheter System. Providing care for critically ill patients often demands a collaborative effort between multiple specialties. This case report exemplifies this collaboration, leading to the combination and unification of alternative treatments: ECMO and catheter assisted thrombolysis.

Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review*

“…About 77 studies were included in this review (Fig. 1) and were assessed for bias using Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (19–95). Our review considered articles to have a low risk of bias if all checklist criteria were met, moderate risk if greater than or equal to 75% of criteria were met, and high risk if less than 75% of criteria were met.…”

Clinical Pearls of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

“…Moreover, if we consider the ECMO's physiology of partial cardiopulmonary bypass, VA ECMO is the most suitable device for the pathophysiology of right heart failure from PTE. After the patient becomes stable, the treatment for the thrombus should be selected among the following options: anticoagulation,25)29) systemic thrombolysis,30) catheter-directed thrombectomy or thrombolysis,31) or surgical embolectomy 24)26). The European Society of Cardiology 2014 acute PTE guidelines briefly mention that ECMO can be used to treat massive PTE as a method for hemodynamic support and as an adjunct to surgical thrombectomy 32).…”

“…The European Society of Cardiology 2014 acute PTE guidelines briefly mention that ECMO can be used to treat massive PTE as a method for hemodynamic support and as an adjunct to surgical thrombectomy 32). Because VA ECMO itself requires systemic anticoagulation, VA ECMO with or without catheter-directed thrombectomy may cure acute PTE 31). Thrombolysis, especially systemic thrombolysis, would to be dangerous under VA ECMO.…”

Use of Ultrasound-Assisted, Catheter-Directed Thrombolysis in a Patient With High-Risk Pulmonary Embolism

“…The patient was weaned off inotropic support by the end of the procedure and had no major bleeding. Giuffrida et al, 7 Nelson et al, 8 and Lindsey et al 9 all reported the use of USAT in patients following cardiac arrest with concerns for trauma as a result of cardiopulmonary resuscitation. Gowda et al 10 illustrated the application of USAT in a pregnant patient at 9 weeks gestation.…”