Extracorporeal membrane oxygenation as rescue therapy for patients with suspected high-risk pulmonary embolism: A multicenter retrospective cohort study

Aims High-risk pulmonary embolism (PE) is life-threatening with high mortality. For patients with suspected high-risk PE who cannot undergo computed tomography pulmonary angiography (CTPA) due to unstable hemodynamics, should ECMO be prioritized as rescue over revascularization? This study evaluates initial ECMO strategies to optimize management in high-risk PE. Methods We retrospectively analyzed clinical data from 117 patients with suspected high-risk PE admitted to four ECMO centers between January 2013 and January 2024. Results Of these 117 patients, 79 initially received ECMO (ECMO group), whereas 38 underwent revascularization (Thrombolysis group). Baseline characteristics and pretreatment interventions (ECMO and thrombolytic therapy) did not differ between the two groups. However, the in-hospital mortality (33/79, 41.8% vs 22/38, 57.9%, P = 0.06) and the incidence of fatal bleeding complications (7/79, 8.9% vs 13/38, 34.2%, P = 0.01) were lower in the ECMO group than in the Thrombolysis group. Among 79 patients who initially received ECMO, CTPA confirmed high-risk PE in 63. Successful ECMO weaning was achieved in 37 patients (37/63, 58.7%), with 34 surviving to hospital discharge (34/63, 53.1%). Linear regression analysis revealed no linear correlation between the severity of pulmonary artery obstruction due to thrombosis (quantified by Qanadli scores) and the severity of the clinical presentation (assessed using pre-ECMO APACHE II scores; P = 0.39). Conclusions For patients with suspected high-risk PE unable to undergo CTPA due to hemodynamic instability, although ECMO is considered potentially beneficial, our study found no statistical difference in patients' in-hospital mortality when ECMO is used as the prioritized initial treatment.