Case report: interventional thrombectomy with haemodynamic support by veno-arterial extracorporeal membrane oxygenation as a rescue strategy in acute pulmonary embolism refractory to systemic thrombolysis.

Background: High-risk pulmonary embolism (PE) is associated with significant mortality. Thrombolysis is the therapy of choice, while interventional thrombectomy may be a helpful strategy in case of contraindications or failed thrombolysis. However, the procedure may be complicated by catheter-induced embolization of clots and/or haemodynamic compromise.

Case summary: We present a 32-year-old patient woman with fulminant pulmonary artery embolism. Despite immediate systemic thrombolysis, the patient remained in cardiogenic shock with rising lactate levels. Furthermore, floating clots were observed in the right atrium of the patient. As a rescue strategy, we performed interventional thrombectomy by using the Inari FlowTriever system supported by periinterventional veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation. After a successful thrombectomy, the patient recovered and showed immediate haemodynamic improvement.

Discussion: Interventional thrombectomy may be considered in patients with high-risk PE and failed thrombolytic therapy. Support by a VA-ECMO should be considered in order to prevent transient haemodynamic instability associated with accidental, catheter-induced clot mobilization from the vena cava or right atrium.