Large bore aspiration and catheter based thrombolytic intervention for high risk pulmonary embolism in patients on veno-arterial extracorporeal membrane oxygenation

Monday, March 31, 2025

3:45 PM – 3:54 PM CT

Location: Music City Center, 201 AB

Presenting Author(s)

Ashab Alamgir

Medical Student
University of Minnesota, United States

Author/Co-author(s)

RP

Rina Petek, DO

Resident
University of Minnesota, United States
AZ

Ahmad Zaro, BA

Medical Student
University of Minnesota, United States
Reza Talaie, MD

Associate Professor
University of Minnesota, United States
Siobhan Flanagan, MD

Associate Professor
University of Minnesota, United States
PS

Prashant Shrestha, MD

Assistant Professor
University of Minnesota, United States

Purpose: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may improve outcomes in subjects with high-risk pulmonary embolism (PE) and circulatory failure. Current guidelines recommend systemic thrombolytic treatment for appropriate candidates. However, it is uncertain if additional catheter-based interventions such as mechanical thrombectomy (MT) or catheter-directed thrombolytics (CDT) during cannulation improves outcomes such as survival. This case series reviews a cohort of 23 patients on VA-ECMO with subsequent catheter-based intervention – with 19 patients presenting with cardiac arrest.

Materials and Methods: Retrospective single-center review of subjects with high-risk PE on VA-ECMO support who underwent catheter-based reperfusion. The primary outcome examined was 30-day mortality.

Results: Twenty one total patients with a mean age of 50 years (±14) and BMI of 38 (±10). Nineteen subjects (91%) experienced cardiac arrest and eight patients (38%) received systemic tPA, prior to VA-ECMO cannulation. The mean time from cannulation to catheter intervention was 12 hours (±26). Subsequent catheter interventions included two subjects undergoing CDT alone (9.5%), nine (43%) MT alone, and ten (48%) combined MT followed by CDT. The 30-day mortality rate for all subjects was 52%. Comparing those who survived at 30 days vs those who did not, survivors were more likely on vasopressors initially (100% vs 55%, p=0.016), less likely to suffer a stroke (0% vs 45%, p=0.008), and required longer mean hospitalization (36 vs 8 days, p=0.25), and ICU stay (20 vs 7 days, p=0.03). Several clinical variables did not significantly impact 30-day mortality including initial RV/LV ratio, troponin, BNP or lactate levels, cardiac arrest prior to cannulation, or time from cannulation to intervention. When comparing catheter-based treatments, there was no significant difference in 30-day mortality between the three groups of CDT alone, MT alone, and MT combined with CDT.

Conclusion: VA-ECMO in high-risk PE patients followed by catheter-based interventions demonstrated a 30-day mortality rate of 52% in this case series. Survivors were more likely on vasopressors prior to cannulation and suffered significantly lower rates of stroke during cannulation. Cardiac arrest prior to cannulation, systemic thrombolytic infusion, time from cannulation to intervention, and type of catheter-based intervention (MT, CDT, or combined MT/CDT) did not significantly impact survival.