Cardiovascular Collapse During Mechanical Thrombectomy For Acute Pulmonary Embolism: The Role of ECMO in Patient Rescue
Bright Benfor, Paul Haddad, Marvin D Atkins, Alan B Lumsden, Eric K. Peden
Houston Methodist Debakey Heart and Vascular Center, Houston, TX
Background Driven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for treatment of massive or submassive pulmonary embolism (PE); as well as their wide-spread adoption by different levels of health care organizations. This study investigated the incidence and outcomes of severe cardiovascular collapse during MT procedures.
Methods This was a single center retrospective review of PE patients undergoing MT with the FlowTriever® device (INARI) between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated.
Results A total of 151 PE patients underwent MT during the study period with intraoperative cardiac arrest occurring in 8/151 (5.3%). Their mean age was 64±10 years and 6/8 were male. Six patients presented a history of recent surgery and concomitant DVT. The mean oxygen saturation upon admission was 90±7% and the simplified pulmonary embolism severity index (sPESI) was > 1 in 6/9 cases, with one patient presenting an episode of cardiac arrest prior to surgery. Preoperative echocardiogram revealed right ventricle (RV) dysfunction in all cases and CT scan demonstrated bilateral PE in all patients with a mean RV/LV ratio of 1.5±0.4, while troponin was elevated in 6/8 cases. All procedures were performed by experienced board-certified vascular surgeons in a hybrid suite with a minimal anesthesia approach and in the presence of highly experienced CV anesthesiologists. Cardiac arrest occurred during active thrombectomy, with the device crossing the right heart in all cases and in each case, there was immediate initiation of CPR. The ready availability of both Extra-corporal-membrane-oxygenation (ECMO) technology and expertise resulted in the rescue of 4/8 patients while the remaining 4 patients who had no ECMO support available expired intraoperatively. Post-arrest echocardiogram showed intact tricuspid valve and severely diminished right ventricular function in all salvaged patients. After 2-4 days of stabilization, residual PE was removed by open embolectomy in 2/4 cases, repeat mechanical thrombectomy with concurrent ECMO support in 1/4, and in 1 case observation and anticoagulation. Patients were discharged home after an average of 15 days with no mortality recorded at 30 days.
Conclusion While the role of mechanical thrombectomy in the treatment of intermediate-high risk PE is well established, our limited experience suggests that the concern for periprocedural cardiovascular collapse is non-negligible and can occur even in well-trained hands, but ECMO may help salvage some of these patients. We therefore recommend this technology be available in all institutions where pulmonary artery mechanical thrombectomy procedures are being performed and vascular surgeons need to be adept at placing of ECMO support to expedite resuscitation when the situation arises.
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