Title:
The utilization of ECMO and mechanical thrombectomy in treatment of a massive pulmonary embolism after failed fibrinolysis.
Introduction:
Massive pulmonary embolism (PE) has been associated with high rates of morbidity and mortality, but mechanical therapies have been rapidly advancing. There are limited data available on the concurrent application of extracorporeal membrane oxygenation (ECMO) and mechanical embolectomy. We present a case that highlights the successful utilization of this combined strategy in an unstable patient who experienced cardiac arrest due to a massive PE despite administration of fibrinolytic therapy prior to transfer.
Clinical Case:
A 45-year-old male with no previous cardiovascular history was brought to the emergency department (ED) via emergency medical services after a fall at home, resulting in loss of consciousness. Family members discovered the patient unresponsive. Upon arrival at the ED, the patient displayed unconsciousness, diaphoresis, tachycardia, and hyperventilation. The initial EKG indicated sinus tachycardia and a newly developed right bundle branch block. According to family, the patient had previously complained of left leg pain around 3 weeks prior and had sought evaluation at an urgent care facility. The patient required immediate intubation. Following intubation, the patient experienced a cardiac arrest, leading to the initiation of cardiopulmonary resuscitation (CPR). Return of spontaneous circulation (ROSC) was achieved after one round of CPR. The patient was found to be in ventricular tachycardia and underwent successful defibrillation. Further evaluation revealed extensive bilateral PEs on CTA Chest. The patient was given a 50 mg dose of alteplase; however, another cardiac arrest occurred, and ROSC was re-established following an additional round of CPR. A second dose of alteplase was given. The patient was urgently transferred to our medical center and the PERT system was activated. Upon arrival at our institution, the patient exhibited hypoxia and hypotension necessitating norepinephrine, epinephrine, and vasopressin drips. A decision was made to perform peripheral veno-arterial ECMO cannulation via the left femoral artery, left femoral vein, and left superficial femoral artery distal to the arterial cannula for distal perfusion. This facilitated an emergent mechanical thrombectomy. An initial pulmonary angiogram revealed nearly complete bilateral main pulmonary artery occlusion. Successful mechanical thrombectomy was completed, resulting in the removal of bulky, organized thrombus bilaterally and improved pulsatility. Post-procedure, a right heart catheterization was performed during ECMO at 3200 rpm, revealing low pulmonary artery pressures. The patient was decannulated surgically from ECMO within 48 hours, however complicated by hemorrhage from the left common femoral artery, necessitating repair. The patient's clinical condition improved, leading to extubation five days after presentation. Ultimately, the patient was discharged on Xarelto. During a three-month follow-up visit, the patient reported no complaints and echocardiogram showed normal right and left ventricular function.
Discussion:
The combined use of ECMO and pulmonary mechanical embolectomy represents a novel intervention that aims to address the challenges posed by massive PE. While both therapies have demonstrated efficacy individually, their concurrent application remains a subject of limited research. Further data will be necessary to evaluate the safety and application for patients presenting with shock and massive PE, particularly after failed fibrinolysis.