Successful rescue of a high-risk pulmonary embolism using thrombolysis, extracorporeal membrane oxygenation, and percutaneous pulmonary thrombectomy: a case report.

Pulmonary embolism (PE) presenting with syncope as an initial symptom is a relatively uncommon condition with a comparatively high rate of mortality (47.5%) that is prone to misdiagnosis as other cardiac and pulmonary diseases. The European Society of Cardiology classifies acute PE with persistent hypotension as high-risk PE. Patients with syncope as the initial symptom often have persistent hypotension and hypoxemia. Although traditional therapeutic approaches, such as thrombolysis and anticoagulation, have limited efficacy in treating this type of acute PE, timely use of extracorporeal membrane oxygenation (ECMO) to stabilize hemodynamics and bridging with percutaneous pulmonary thrombectomy (PPT), is an effective method in cases of high-risk PE presenting with syncope as the initial symptom. In this report, we describe the case of a 48-year-old man with no history of previous cardiac or pulmonary diseases, who had experienced sudden syncope 3 days prior to admission. Following admission, he developed cardiogenic shock [heart rate 125 beats per min, systolic blood pressure (SBP) 87 mmHg, lactate 5.2 mmol/L]. Computed tomography pulmonary angiography revealed massive bilateral PE. Although thrombolytic therapy was promptly administered, the patient continued to experience persistent hypotension (SBP 67 mmHg) and refractory hypoxemia (SaO2 73%). ECMO was initiated, achieving hemodynamic stabilization within 30 min (SBP 95 mmHg, SaO2 99%). Echocardiography revealed right ventricular dysfunction. To reduce pulmonary artery pressure and prevent further right heart failure, we performed emergency PPT under ECMO support. The patient was discharged on day 14 with no neurological deficits. This case highlights the efficacy of ECMO as a bridge to definitive therapy, combined with prompt PPT, in the management of high-risk PE with hemodynamic collapse. The successful outcome in this case emphasizes the importance of structured, protocol-driven hemodynamic support using ECMO and timely surgical intervention in preventing right ventricular failure.