--Massive PE is defined as PE with obstructive shock (hypotension [SBP <90] or end-organ malperfusion)
--Consider venoarterial (VA) ECMO in massive PE for hemodynamic support, particularly prior to intubation
--VA ECMO may prevent intubation/mechanical ventilation, surgical intervention, systemic and local thrombolysis
Answer
--Patients on VA ECMO require systemic anti-coagulation to prevent arterial embolism. So, patients with relative and absolute contraindications to catheter-directed and systemic thrombolysis should be considered for VA ECMO for HD support while AC works.
--Intubating already hemodynamically tenuous patients is dangerous and increases in intra-thoracic pressure worsens RV failure and suppressing patient's catecholamine drive with sedation during RSI may also worsen hemodynamics.
--Frequently, patients who get VA ECMO will not require surgical embolectomy as the clot burden will resolve after a few days of heparin. And RV function with improve as demonstrated by serial echocardiography
--A recent review showed an overall survival of 70% in VA ECMO patients for massive PE. This included patients already in cardiac arrest. Review included case series, cohorts, but no RCTs.
