Venoarterial extracorporeal membrane oxygenation as a rescue strategy in high-risk pulmonary thromboembolism.

Acute high-risk pulmonary thromboembolism (PTE) is the most severe clinical manifestation of venous thromboembolism, carrying a substantial mortality rate, particularly when complicated by cardiogenic shock or cardiac arrest. Although current guidelines recommend systemic thrombolysis for high-risk PTE in the absence of contraindications, this approach is associated with a significant risk of major hemorrhage and may be precluded in patients with severe comorbidities, advanced frailty, or elevated perioperative risk. Consequently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an important mechanical circulatory support strategy for this vulnerable cohort. By bypassing the obstructed pulmonary vascular bed, VA-ECMO facilitates rapid hemodynamic stabilization, mechanically unloads the strained right ventricle, and reverses systemic hypoperfusion. This review elucidates the pathophysiological rationale for right ventricular unloading in high-risk PTE and examines the evolving approach toward catheter-directed interventions and patient-tailored treatment strategies. Furthermore, we evaluate the clinical outcomes of VA-ECMO when deployed either as a stand-alone therapy bridge to recovery alongside systemic anticoagulation or as a bridge to definitive active thrombus clearance.