Surgical Embolectomy for tPA Refractory Pulmonary Embolism Requiring VA-ECMO: A Case Report and Literature Review

Pulmonary embolism (PE) is a significant cause of morbidity and mortality worldwide. In the USA, it is estimated that 900,000 people are affected annually. Mortality in high-risk PE remains as high as 50%. Despite significant advances in diagnosis and treatment, management of intermediate high- and high-risk PE remains challenging. While systemic anticoagulation is the cornerstone of treatment, available data supporting more advanced interventions, especially in high-risk populations, is lacking. In this manuscript, we share our experience in managing a patient with high-risk PE through sequential escalation of care, ultimately requiring surgical thrombectomy supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We also provide a detailed review of the latest evidence on VA-ECMO use in the high-risk PE population. Cardiovascular support with VA-ECMO should be considered early in the management of patients with high-risk PE.