SIR 2024
Venous Interventions
Ernest N. Barral, B.S. (he/him/his)
Medical Student
Duke School of Medicine
Financial relationships: Full list of relationships is listed on the CME information page.
Jon G. Martin, MD (he/him/his)
Assistant Professor of Radiology
Duke University Medical Center
Disclosure information not submitted.
Charles Y. Kim, MD, FSIR
Professor and Chief of Interventional Radiology
Duke University
Financial relationships: Full list of relationships is listed on the CME information page.
James Ronald, MD, PhD
Associate Professor of Radiology
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Waleska Pabon-Ramos, MD, MPH (she/her/hers)
Associate Professor of Radiology
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Brendan Cline, MD
Assistant Professor of Radiology
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Nicholas T. Befera, MD
Assistant Professor
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Alan Alper Sag, MD
Assistant Professor, Interventional Radiology and Orthopaedic Surgery
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Paul Suhocki, MD
Associate Professor of Radiology
Duke University Medical Center
Disclosure information not submitted.
Tony P. Smith, MD
Professor of Radiology
Duke University Medical Center
Disclosure information not submitted.
Patients with acute massive pulmonary embolism (PE) requiring emergent extracorporeal membrane oxygenation (ECMO) have poor survival outcomes, with published in-hospital mortality rates of 46.9%-61.6%. {1} However, ECMO may provide a promising avenue to maintain or restore hemodynamic stability in critically ill patients as a bridge to potentially life-saving mechanical PE intervention. A prior retrospective review demonstrated the potential for effective combination of ECMO and catheter-directed thrombolytics {2}, but no such review exists for ECMO in combination with large bore aspiration thrombectomy (LBAT). Here we present a case series of 18 such patients.
Materials and Methods:
This case series was based on patients at a single institution who underwent LBAT for acute massive PE after initiation of ECMO, from Jan. 2015 to March 2023. An internal procedural database was queried for PE thrombectomy procedures, and electronic health records were reviewed for selected periprocedural clinical values, reports and images, and post procedural follow up. Primary outcomes were 48-hour and 30-day mortality and procedure-related complications within 30 days of intervention.
Results:
18 patients were reviewed, including 13 on VA-ECMO, 2 on VV-ECMO, and 3 on V-AV ECMO prior to and during aspiration thrombectomy. 48-hour mortality was 22.2% and 30-day mortality was 38.9%. Three patients (16.67%) experienced severe adverse events and 8 patients (44.44%) experienced additional mild or moderate complications attributable to ECMO or PE intervention. Among severe AEs, 2 patients experienced acute ischemic strokes following procedure, and 1 patient had a massive cerebral hemorrhage with consequent loss of brainstem function. 10 patients had same-modality pre- and post-procedure imaging, allowing for direct comparison. Of these, 9 patients (90%) showed improvement of RV/LV ratio on CT or RV function on echocardiogram.
Conclusion:
In conclusion, this review shows that LBAT can be effectively used in the setting of ECMO for patients with acute massive PE. While ECMO can reduce the risk of acute hemodynamic collapse, VA-ECMO in particular increases the risk of arterial embolism by creating a large right-to-left shunt, and thus, should be taken into consideration when LBAT is being considered. However, patients who are on ECMO are likely to be critically ill and may require LBAT despite the high risk involved. Ultimately, the decision to pursue PE thrombectomy in these cases should be made on a case-by-case basis with careful consideration of the potential risks and benefits of treatment.