Abstract Background High-risk pulmonary embolism (PE) is associated with an in-hospital fatality exceeding 20% and peaking 90% after cardiopulmonary resuscitation (CPR). Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be necessary for the most severe cases to achieve hemodynamic stabilization and bridge to percutaneous or surgical mechanical thrombus removal. Purpose To evaluate the efficacy and safety of percutaneous large-bore aspiration embolectomy using a large-bore thrombectomy device in patients with high-risk PE with VA-ECMO support or standby. Methods In this retrospective cohort study, we studied all patients with acute high-risk PE treated with large-bore percutaneous aspiration embolectomy at an academic center (2021–2024) after multidisciplinary assessment. We stratified patients according to the VA-ECMO strategy: (1) catheter-directed embolectomy on ECMO (pre-procedural ECMO) and (2) catheter-directed embolectomy with ECMO-standby (contralateral venous and arterial access, ECMO team as back-up). We studied in-hospital all-cause and PE-related death, PE recurrence, immediate technical success, and periprocedural upgrade to VA-ECMO for patients not initially under ECMO. Bleeding events (GUSTO criteria) were recorded. Results Among 45 consecutive patients undergoing percutaneous embolectomy (20% women, median age 64 Q1, Q3: 53, 74 years), 13 (29%) presented with cardiac arrest, 16 (36%) with obstructive shock/decompensation, and 16 (36%) with normotensive shock, as evidenced by signs of reduced tissue perfusion, respiratory insufficiency encompassing high-flow oxygen or intubation, or lactate levels 2 mmol/L. An absolute contraindication to systemic thrombolysis was present in 20 (44%) of patients. A bolus of alteplase was administered before hospital transfer or admission to 8 (18%) patients (Table). Sixteen (36%) patients were on pre-procedural VA-ECMO and 29 (64%) on ECMO-standby (Table). Bailout-intraprocedural VA-ECMO was needed due to cardiac arrest or worsening shock in 5 out of 29 patients (17%). Immediate technical success exceeded 95%. Among 13 patients with cardiac arrest, PE-related death rate was 31%. Among 16 patients with obstructive shock, PE-related death rate was 12%. No patient with initial normotensive shock died (Figure). Overall, in-hospital PE recurrence was 4%. Severe or moderate GUSTO bleeding was observed in 31% of patients with pre-procedural ECMO and 7% of those on ECMO-standby. Conclusions Percutaneous large-bore aspiration embolectomy with VA-ECMO support or standby is feasible across the spectrum of high-risk PE. Initial PE severity correlates with mortality and hemodynamic decompensation. VA-ECMO upgrade was needed in a substantial proportion of patients and appears a reasonable strategy to prevent periprocedural death in patients with high-risk PE.Table Figure
Fumagalli et al. (Sat,) studied this question.