Peri-operative massive pulmonary embolism management: is veno-arterial ECMO a therapeutic option?

Pulmonary embolism remains an important clinical problem with a high mortality rate. The potential for sudden and fatal hemodynamic deterioration highlights the need for a prompt diagnosis and appropriate intervention. The purpose of the present case report is to describe a successful peri-operative veno-arterial extra corporeal membrane oxygenation (VA-ECMO) implantation for assumed massive pulmonary embolism associated with high hemodynamic instability and severe hypoxemia. A 52-year-old female victim of a motorcycle accident had been operated on for unstable fractures that required optimal repair. Despite subcutaneous administration of 40 mg enoxaparin on day 0 and day 1, the patient developed a massive pulmonary embolism leading to peri-operative pulseless activity. As intravenous thrombolysis was strictly contraindicated, a VA-ECMO was successfully implanted and permitted to stabilize the patient's hemodynamics. The hemodynamic and respiratory status improved by day 3, and the ECMO was removed. A vena cava filter was implanted before successful and definitive stabilization of the femoral fracture and the L2 fracture on days 4 and 5. The patient was able to be mobilized 2 days after the surgery and was transferred to a rehabilitation ward on day 15. At that time, her cognitive functions had fully recovered. ECMO can provide lifesaving hemodynamic and respiratory support in patients with massive pulmonary embolism who are too unstable to tolerate other interventions, who have failed other therapies or for whom other therapies are contraindicated.