ECMO-assisted catheter-directed thrombolysis for post-traumatic pulmonary embolism with bilateral atrial thrombi: a retrospective case series

We retrospectively evaluated the feasibility and short-term outcomes of extracorporeal membrane oxygenation (ECMO)–assisted catheter-directed thrombolysis in this high-risk population and descriptively characterized the accompanying biomarker trajectories. We retrospectively reviewed 16 adults presenting 9–13 days post-trauma with CT pulmonary angiography (CTA)-confirmed extensive bilateral PE and transesophageal echocardiography (TEE)-verified atrial thrombi who underwent V-A ECMO–assisted CDT in a single tertiary center. Primary outcomes were imaging-documented thrombus resolution, hemodynamic stabilization, in-hospital survival, and 90-day functional status. A streamlined biomarker panel—including a coagulation profile (D-dimer, fibrinogen, aPTT, anti-Xa, PT/INR), cardiac markers (troponin, BNP), and markers of perfusion/hemolysis (lactate, free hemoglobin, LDH) plus IL-6, and at decreasing frequencies post-wean as a secondary, exploratory monitoring tool. In this retrospective case series of 16 adults with post-traumatic PE and bilateral atrial thrombi, ECMO-assisted catheter-directed thrombolysis was technically feasible in all patients and was not interrupted for device- or access-related complications. Median ECMO duration was 6 days (IQR 5–7), and median hospital stay was 14 days (IQR 12–16). Survival was 15 of 16 (93.8%): one patient died of hemorrhagic shock and one of sepsis. Among survivors, complete radiographic resolution of both pulmonary and atrial thrombi was documented before discharge. Hemodynamic and perfusion indices improved after ECMO/CDT, with mean arterial pressure rising from 60 to 75 mmHg and arterial lactate falling from 5.2 to 2.1 mmol/L. Over 90 days of follow-up, no recurrent thrombotic events were detected; 13 of 14 survivors (93%) returned to baseline functional status (NYHA I), and one reported mild exertional dyspnea (NYHA II). Serial biomarker measurements showed concordant, statistically significant declines in D-dimer, troponin I, BNP, and lactate over the course of ECMO-assisted thrombolysis (all p < 0.05), paralleling imaging and hemodynamic evidence of clot resolution and supporting our descriptive characterization of biomarker trajectories as adjunctive endpoints. In patients with post-traumatic PE and bilateral atrial thrombi, ECMO-assisted catheter-directed thrombolysis was associated with hemodynamic stabilization and complete radiographic thrombus clearance in most survivors, while serial biomarker measurements provided adjunctive information on coagulation, cardiac strain, and perfusion.