Venoarterial Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Practical Guide to Patient Selection, Timing, and Management

Le résumé fourni par la source

Background The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for pulmonary embolism (PE) has increased substantially. However, optimal strategies for patient selection and management are not well established. Objectives The primary objective was to systematically review studies of patients with high-risk PE supported by VA-ECMO and to identify characteristics distinguishing survivors from nonsurvivors. The secondary objective was to review best practices in pre-ECMO management, reperfusion therapies, and anticoagulation, and to introduce the Traffic Light Algorithm to optimize patient selection. Methods An updated systematic review of observational studies involving patients with PE supported with VA-ECMO was conducted. Systematic Review Findings Among 50 observational studies including 1125 patients with high-risk PE on VA-ECMO, 63% experienced cardiac arrest and 48.8% had contraindications to thrombolysis. Survivors had shorter cardiopulmonary resuscitation durations and lower pre-ECMO lactate levels. Among survivors, 84.4% were neurologically intact. Discussion Observational data suggest that VA-ECMO for PE is associated with lower mortality compared with other indications for extracorporeal support, especially in patients without pre-cannulation cardiac arrest. Careful pre-cannulation hemodynamic management is critical to prevent cardiovascular collapse. Reperfusion and anticoagulation strategies should balance the benefits of clot removal against bleeding risks. The current variability in initiation timing, concurrent reperfusion therapies, anticoagulation targets, and patient selection reflects the urgent need for prospective registries and randomized trials. Until such studies are completed, VA-ECMO use should be guided by structured approaches such as the Traffic Light Algorithm, with early involvement of the pulmonary embolism response team to inform patient selection for extracorporeal support and reperfusion therapies.

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