Evidence-Based Minireview: Advanced therapies and extracorporeal membrane oxygenation for the management of high-risk pulmonary embolism

Gangaraju, Radhika; Klok, Frederikus A.

doi:10.1182/hematology.2020000167

Cited by 6 publications

(5 citation statements)

References 49 publications

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“…Haemorrhagic complications are more commonly reported amongst those who receive systemic thrombolysis and ECMO, which might explain the higher mortality in those who received ECMO and systemic thrombolysis in our meta-analysis [ 67 ]. Notably, some ECMO centres prohibit systemic thrombolysis due to the increased risk of lethal haemorrhage [ 4 , 10 ].…”

Section: Discussionmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis

Boey,

Dhundi,

Ling

et al. 2023

JCM

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Background: The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with other curative therapies. We aimed to characterise the mortality of adults with HRPE treated with ECMO, identify factors associated with mortality, and compare different adjunct curative therapies. Methods: We conducted a systematic review and meta-analysis, searching four international databases from their inception until 25 June 2023 for studies reporting on more than five patients receiving ECMO for HRPE. Random-effects meta-analyses were conducted. The primary outcome was in-hospital mortality. A subgroup analysis investigating the outcomes with curative treatment for HRPE was also performed. The intra-study risk of bias and the certainty of evidence were also assessed. This study was registered with PROSPERO (CRD42022297518). Results: A total of 39 observational studies involving 6409 patients receiving ECMO for HRPE were included in the meta-analysis. The pooled mortality was 42.8% (95% confidence interval [CI]: 37.2% to 48.7%, moderate certainty). Patients treated with ECMO and catheter-directed therapy (28.6%) had significantly lower mortality (p < 0.0001) compared to those treated with ECMO and systemic thrombolysis (57.0%). Cardiac arrest prior to ECMO initiation (regression coefficient [B]: 1.77, 95%-CI: 0.29 to 3.25, p = 0.018) and pre-ECMO heart rate (B: −0.076, 95%-CI: −0.12 to 0.035, p = 0.0003) were significantly associated with mortality. The pooled risk ratio when comparing mortality between patients on ECMO and those not on ECMO was 1.51 (95%-CI: 1.07 to 2.14, p < 0.01) in favour of ECMO. The pooled mortality was 55.2% (95%-CI: 47.7% to 62.6%), using trim-and-fill analysis to account for the significant publication bias. Conclusions: More than 50% of patients receiving ECMO for HRPE survive. While outcomes may vary based on the curative therapy used, early ECMO should be considered as a stabilising measure when treating patients with HRPE. Patients treated concurrently with systemic thrombolysis have higher mortality than those receiving ECMO alone or with other curative therapies, particularly catheter-directed therapies. Further studies are required to explore ECMO vs. non-ECMO therapies in view of currently heterogenous datasets.

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Section: Discussionmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis

Boey,

Dhundi,

Ling

et al. 2023

JCM

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“…Growing data suggest that specific high-risk patients with massive or submassive PE and/or clot in transit may have both survival and symptomatic benefit from advanced therapies in comparison to anticoagulation alone [ 1 , 3 – 7 , 9 – 10 ]. Long-term data for catheter-related therapies are lacking and mostly based on smaller case series [ 7 ].…”

Section: Discussionmentioning

confidence: 99%

Contemporary management of intracardiac thrombi: a tale of two clots

Branigan¹,

Brown²,

Zavala³

et al. 2023

J Extra Corpor Technol

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“…This protective ventilation strategy for open lungs allows the lungs to rest, thereby increasing time available to treat the original disease[ 16 ]. ECMO has been used in the following clinical scenarios for PE patients[ 15 , 17 , 18 ]: (1) To rescue patients when thrombolytic treatment fails or as a temporary hemodynamic support prior to performing intervention; and (2) To treat patients with refractory cardiogenic shock or cardiac arrest. Our patient experienced cardiac arrest and was both hemodynamically unstable and unable to tolerate interventional surgery and, as a result, he underwent ECMO therapy.…”

Section: Discussionmentioning

confidence: 99%

Combined use of extracorporeal membrane oxygenation with interventional surgery for acute pancreatitis with pulmonary embolism: A case report

Liu¹,

Jin²,

Yan³

et al. 2022

WJCC

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BACKGROUND Acute pancreatitis (AP) is an acute inflammatory process of the pancreas characterized by self-digestion of pancreatic tissue, which can trigger a systemic inflammatory response. Venous thrombosis, resulting from a hypercoagulable state, is a vascular complication of AP. AP complicated by pulmonary embolism (PE) is very rare, and the combined use of extracorporeal membrane oxygenation (ECMO) with a vascular interventional procedure for AP complicated by PE is even rarer. CASE SUMMARY A 32-year-old man with a history of obesity developed rapidly worsening AP secondary to hypertriglyceridemia. During treatment, the patient developed chest tightness, shortness of breath, and cardiac arrest. Computed tomography (CT) scans of his upper abdomen were consistent with pancreatitis. PE was identified by chest CT angiography involving the right main pulmonary artery and multiple lobar pulmonary arteries. The patient’s D-dimer level was significantly elevated (> 20 mg/L). The patient received high-frequency oxygen inhalation, continuous renal replacement therapies, anti-infective therapy, inhibition of pancreatic secretion, emergent endotracheal intubation, and advanced cardiac life support with cardiopulmonary resuscitation. Following both ECMO and a vascular interventional procedure, the patient recovered and was discharged. CONCLUSION PE is a rare but potentially lethal complication of AP. The early diagnosis of PE is important because an accurate diagnosis and timely interventional procedures can reduce mortality. The combined use of ECMO with a vascular interventional procedure for AP complicated by PE can be considered a feasible treatment method. A collaborative effort between multiple teams is also vital.

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Evidence-Based Minireview: Advanced therapies and extracorporeal membrane oxygenation for the management of high-risk pulmonary embolism

Cited by 6 publications

References 49 publications

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis

Contemporary management of intracardiac thrombi: a tale of two clots

Combined use of extracorporeal membrane oxygenation with interventional surgery for acute pancreatitis with pulmonary embolism: A case report

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