Massive pulmonary embolism (MPE) is a rare but highly fatal condition. Our study’s objective was to evaluate the association between advanced interventions and survival among patients with MPE treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO).
Methods
This is a retrospective review of the Extracorporeal Life Support Organization (ELSO) registry data. We included adult patients with MPE who were treated with VA-ECMO during 2010–2020. Our Primary outcome was survival to hospital discharge; secondary outcomes were ECMO duration among survivors and rates of ECMO-related complications. Clinical variables were compared using the Pearson chi-square and Kruskal-Wallis H tests.
Results
We included 802 patients; 80 (10%) received SPE and 18 (2%) received CDT. Overall, 426 (53%) survived to discharge; survival was not significantly different among those treated with SPE or CDT on VA-ECMO (70%) versus VA-ECMO alone (52%) or SPE or CDT before VA-ECMO (52%). Multivariable regression found a trend towards increased survival among those treated with SPE or CDT while on ECMO (AOR 1.8, 95% CI 0.9–3.6), but no significant correlation. There was no association between advanced interventions and ECMO duration among survivors, or rates of ECMO-related complications.
Conclusion
Our study found no difference in survival in patients with MPE who received advanced interventions prior to ECMO, and a slight non-significant benefit in those who received advanced interventions while on ECMO.
SecemskyEChangYJainCC, et al.Contemporary management and outcomes of patients with massive and submassive pulmonary embolism. Am J Med2018; 131(12): 1506–1514. DOI: 10.1016/j.amjmed.2018.07.035
2.
KasperWKonstantinidesSGeibelA, et al.Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol1997; 30(5): 1165–1171. DOI: 10.1016/s0735-1097(97)00319-7
ScottJHGordonMVenderR, et al.Venoarterial extracorporeal membrane oxygenation in massive pulmonary embolism-related cardiac arrest: a systematic review. Crit Care Med2021; 49(5): 760–769. DOI: 10.1097/CCM.0000000000004828
5.
JaffMRMcMurtryMSArcherSL, et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American heart association. Circulation2011; 123(16): 1788–1830. DOI: 10.1161/CIR.0b013e318214914f
6.
MeneveauNSerondeMFBlondeMC, et al.Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest2006; 129(4): 1043–1050. DOI: 10.1378/chest.129.4.1043
7.
KuoWTvan den BoschMAAJHofmannLV, et al.Catheter-directed embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis. Chest2008; 134(2): 250–254. DOI: 10.1378/chest.07-2846
8.
SagSNasOFKaderliAA, et al.Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis. J Thromb Thrombolysis2016; 42(3): 322–328. DOI: 10.1007/s11239-016-1370-3
9.
KearonCAklEAOrnelasJ, et al.Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest2016; 149(2): 315–352. DOI: 10.1016/j.chest.2015.11.026
10.
SakumaMNakamuraMYamadaN, et al.Percutaneous cardiopulmonary support for the treatment of acute pulmonary embolism: summarized review of the literature in Japan including our own experienceAnn Vasc Dis2009; 2(1): 7–16.
11.
GeorgeBParazinoMOmarHR, et al.A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support. Resuscitation2018; 122: 1–5. DOI: 10.1016/j.resuscitation.2017.11.034
12.
CorsiFLebretonGBréchotN, et al.Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation. Crit Care2017; 21(1): 76. DOI: 10.1186/s13054-017-1655-8
13.
WatanabeYSakakuraKAkashiN, et al.Veno-arterial extracorporeal membrane oxygenation with conventional anticoagulation can be a best solution for shock due to massive PE. Int Heart J2017; 58(5): 831–834. DOI: 10.1536/ihj.16-483
14.
MaggioPHemmilaMHaftJ, et al.Extracorporeal life support for massive pulmonary embolism. J Trauma2007; 62(3): 570–576. DOI: 10.1097/TA.0b013e318031cd0c
15.
ElbadawiAMentiasAElgendyIY, et al.National trends and outcomes for extra-corporeal membrane oxygenation use in high-risk pulmonary embolism. Vasc Med2019; 24(3): 230–233. DOI: 10.1177/1358863X18824650
16.
DesaiHNattBBimeC, et al.Pulmonary embolism with right ventricular dysfunction: who should receive thrombolytic agents?Am J Med2017; 130(1): e29–e93. DOI: 10.1016/j.amjmed.2016.07.023
17.
SmithSBGeskeJBKathuriaP, et al.Analysis of national trends in admissions for pulmonary embolism. Chest2016; 150(1): 35–45. DOI: 10.1016/j.chest.2016.02.638
18.
TamarizLHarkinsTNairV. A systematic review of validated methods for identifying venous thromboembolism using administrative and claims data: detection of venous thromboembolism in claims. Pharmacoepidemiol Drug Saf2012; 21(Suppl 1): 154–162. DOI: 10.1002/pds.2341
19.
SchmidtMBurrellARobertsL, et al.Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J2015; 36(33): 2246–2256. DOI: 10.1093/eurheartj/ehv194
20.
ChenWHuangKYaoC, et al.The modified SAVE score: predicting survival using urgent veno-arterial extracorporeal membrane oxygenation within 24 hours of arrival at the emergency department. Crit Care2016; 20(336): 336. DOI: 10.1186/s13054-016-1520-1
21.
MeneveauNGuillonBPlanquetteB, et al.Outcomes after extracorporeal membrane oxygenation for the treatment of high-risk pulmonary embolism: a multicentre series of 52 cases. Eur Heart J2018; 39(47): 4196–4204. DOI: 10.1093/eurheartj/ehy464
22.
PasrijaCKronfliAGeorgeP, et al.Utilization of veno-arterial extracorporeal membrane oxygenation for massive pulmonary embolism. Ann Thorac Surg2018; 105(2): 498–504. DOI: 10.1016/j.athoracsur.2017.08.033
23.
LiuZChenJXuX, et al.Extracorporeal membrane oxygenation—first strategy for acute life-threatening pulmonary embolism. Front Cardiovasc Med2022; 9: 875021. DOI: 10.3389/fcvm.2022.875021
24.
GiraudRLaurencetMAssoulineB, et al.Can VA-ECMO Be used as an adequate treatment in massive pulmonary embolism?J Clin Med2021; 10(15): 3376. DOI: 10.3390/jcm10153376
25.
O’MalleyTJChoiJHMaynesEJ, et al.Outcomes of extracorporeal life support for the treatment of acute massive pulmonary embolism: a systematic review. Resuscitation2020; 146: 132–137. DOI: 10.1016/j.resuscitation.2019.11.018
PasrijaCKonZ. A protocolized approach to veno-arterial extracorporeal membrane oxygenation for massive pulmonary embolism. Resuscitation2018; 126: e12. DOI: 10.1016/j.resuscitation.2018.01.034
30.
DolmatovaEVMoazzamiKCockeTP, et al.Extracorporeal membrane oxygenation in massive pulmonary embolism. Heart Lung2017; 46(2): 106–109. DOI: 10.1016/j.hrtlng.2016.11.005
31.
VanniSJimenezDNazerianP, et al.Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate. Thorax2015; 70(4): 333–338. DOI: 10.1136/thoraxjnl-2014-206300
32.
KolkailahAAHirjiSPiazzaG, et al.Surgical pulmonary embolectomy and catheter-directed thrombolysis for treatment of submassive pulmonary embolism. J Card Surg2018; 33(5): 252–259. DOI: 10.1111/jocs.13576
33.
LoyalkaPAnsariMZCheemaFH, et al.Surgical pulmonary embolectomy and catheter-based therapies for acute pulmonary embolism: a contemporary systematic review. J Thorac Cardiovasc Surg2018; 156(6): 2155–2167. DOI: 10.1016/j.jtcvs.2018.05.085
34.
KaramiMMandigersLMirandaDDR, et al.Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. J Crit Care2021; 64: 245–254. DOI: 10.1016/j.jcrc.2021.03.006
35.
AvgerinosEAliAATomaC, et al.Catheter-directed thrombolysis versus suction thrombectomy in the management of acute pulmonary embolism. J Vasc Surg2018; 67(2): e28. DOI: 10.1016/j.jvs.2017.11.013
36.
Al-BawardyRRosenfieldKBorgesJ, et al.Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a case series and review of the literature. Perfusion2019; 34(1): 22–28. DOI: 10.1177/0267659118786830
37.
LinTWTsaiMTHuYN, et al.Simultaneous thrombolysis and extracorporeal membrane oxygenation for acute massive pulmonary emboli. Ann Thorac Surg2021; 111(3): 923–929. DOI: 10.1016/j.athoracsur.2020.05.155
38.
PrasadNKBoyajianGTranD, et al.Veno-arterial extracorporeal membrane oxygenation for pulmonary embolism after systemic thrombolysis. Semin Thorac Cardiovasc Surg2022; 34(2): 549–557. DOI: 10.1053/j.semtcvs.2021.04.004
39.
MandigersLScholtenERietdijkWJR, et al.Survival and neurological outcome with extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest caused by massive pulmonary embolism: a two center observational study. Resuscitation2019; 136: 8–13. DOI: 10.1016/j.resuscitation.2018.12.008
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
