ID:161 FC-D11-4 Veno-Arterial Extracorporeal Membrane Oxygenation as a Primary Rescue Strategy with Optional Surgical Embolectomy for Massive Pulmonary Embolism: A 10-Year Single-Center Experience

Background: Massive pulmonary embolism (MPE) with refractory obstructive shock or cardiac arrest carries mortality exceeding 30–65%. Systemic thrombolysis, the guideline-recommended first-line therapy, entails significant hemorrhagic risk and delayed hemodynamic effect. We adopted an institutional protocol of immediate VA-ECMO as the primary rescue strategy – entirely bypassing thrombolysis – with selective surgical embolectomy. We report a 10-year single-center experience with VA-ECMO–first approach. Methods: Retrospective study of consecutive MPE patients treated with VA-ECMO at Haeundae Paik Hospital (February 2016–February 2026); peripheral femoral VA-ECMO was the immediate first-line intervention. Surgical embolectomy was performed selectively for persistent hemodynamic compromise. Primary outcome: survival to discharge, 30-day mortality Secondary outcomes: ECMO weaning rate, limb ischemia, major bleeding and ICU stay. Results: Twenty-four patients (female 54.2%; median age 67 years [range 18–83]) underwent VA-ECMO for MPE; 10 (41.7%) presented in cardiac arrest (median CPR time 12.5 min). Median pre-ECMO peak lactate was 9.0 mmol/L; Median ECMO duration was 104 hours (range 4–240). ECMO weaning was achieved in 23 patients (95.8%). Surgical embolectomy was performed in 8 (33.3%) at a median 7.5 hours post-ECMO cannulation. Six patients (25.0%) were managed on awake non-intubated ECMO. No patient developed limb ischemia. One patient underwent reoperation due to surgical site bleeding. Survival to discharge was 83.3% (n=20); 30-day mortality was 12.5% (n=3). Median ICU stay was 12 days. Non-survivors were older (79.0 vs. 55.2 years) with higher pre-ECMO lactate (12.2 vs. 8.0 mmol/L). Conclusions: A thrombolysis-free VA-ECMO–first strategy with selective surgical embolectomy achieved 83.3% survival to discharge and 95.8% ECMO weaning rate in MPE patients. Our results support VA-ECMO as a definitive primary strategy, not merely a rescue bridge, at experienced centers.