Massive Pulmonary Embolism: Extracorporeal Membrane Oxygenation and Surgical Pulmonary Embolectomy

Abstract

Massive pulmonary embolism (PE) refers to large emboli that cause hemodynamic instability, right ventricular failure, and circulatory collapse. According to the 2016 ACCP Antithrombotic Guidelines, therapy for massive PE should include systemic thrombolytic therapy in conjunction with anticoagulation and supportive care. However, in patients with a contraindication to systemic thrombolytics or in those who fail the above interventions, extracorporeal membrane oxygenation (ECMO) and/or surgical embolectomy may be used to improve oxygenation, achieve hemodynamic stability, and successfully treat massive PE. Randomized controlled human trials evaluating ECMO in this context have not been done, and its role has not been well-defined. The European Society of Cardiology 2014 acute PE guidelines briefly mention that ECMO can be used for massive PE as a method for hemodynamic support and as an adjunct to surgical embolectomy. The 2016 CHEST Antithrombotic Therapy for venous thromboembolism Disease guidelines do not mention ECMO in the management of massive PE. However, multiple case reports and small series cited benefit with ECMO for massive PE. Further, ECMO may facilitate stabilization for surgical embolectomy. Unfortunately, ECMO requires full anticoagulation to maintain the functionality of the system; hence, significant bleeding complicates its use in 35% of patients. Contraindications to ECMO include high bleeding risk, recent surgery or hemorrhagic stroke, poor baseline functional status, advanced age, neurologic dysfunction, morbid obesity, unrecoverable condition, renal failure, and prolonged cardiopulmonary resuscitation without adequate perfusion of end organs. In this review, we discuss management of massive PE, with an emphasis on the potential role for ECMO and/or surgical embolectomy.

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

“…The temporary use of mechanical cardiopulmonary support, mostly with veno-arterial extracorporeal membrane oxygenation (ECMO), may be helpful in patients with high-risk PE, and circulatory collapse or cardiac arrest. Survival of critically ill patients has been described in a number of case series [247][248][249][250][251][252], but no RCTs testing the efficacy and safety of these devices in the setting of high-risk PE have been conducted to date. Use of ECMO is associated with a high incidence of complications, even when used for short periods, and the results depend on the experience of the centre as well as patient selection.…”

Post traumatic inferior vena cava thrombosis: A case report and review of literature

“…Patients with contraindication to systemic thrombolytics, extracorporeal membrane oxygenation (ECMO) and/or surgical embolectomy may be used to improve oxygenation, achieve hemodynamic stability and successfully treat massive pulmonary embolism. The most common complication from ECMO and pulmonary embolectomy with cardiopulmonary bypass is bleeding due to systemic anticoagulation, thrombocytopenia and platelet dysfunction [21].…”

Extra-corporeal membrane oxygenation and outcomes in massive pulmonary embolism: Two eras at an urban tertiary care hospital

“…Supporting our findings, several case reports and small case series have suggested that ECMO may have a role in decreasing mortality in patients with massive PE. [4][5][6][7][8][9][10][11][12] One case series spanning 13 years included 21 patients with massive PE, 13 of whom developed cardiogenic shock and eight that had ongoing cardiac arrest. Thirteen of the 21 patients (62%) survived to 1 year.…”

“…3 As hemodynamic improvement is not often immediate after treatment for highrisk PE, extra-corporeal membrane oxygenation (ECMO) has been suggested for cardiopulmonary support either as a bridge to therapy or as support after therapy. [4][5][6][7][8][9][10][11][12] Through bypass of the failing right ventricle and lungs, ECMO maintains cardiac output and mitigates end-organ damage while definitive PE treatment is undertaken. Utilization of ECMO may allow for aggressive treatment of high-risk PE -including administration of thrombolytic medications, catheterdirected interventions, and surgical embolectomy.…”

“…Emerging but limited data suggest that aggressive management of high-risk PE, including the institution of ECMO, may improve morbidity and mortality in massive PE. [4][5][6][7][8][9][10][11][12] Thus, ECMO has been employed in our institution with the aim of improving hemodynamic parameters and clinical outcomes in patients with highrisk PE.…”