(1181) Functional Saddle Pulmonary Embolism in Pediatric Patient Requiring ECMO and Mechanical Thrombectomy

Introduction: Pulmonary embolism (PE) in children is rare, and acute massive PE with cor pulmonale is exceedingly so. In adults, mortality rates for acute massive PE exceed 20%. Though pediatric data is limited, studies show mortality for PE of all severities around 8%. Pediatric PE often goes unrecognized, suggesting that morbidity and mortality may be underestimated. Evidence-based management guidelines are limited and current practices are mostly extrapolated from adult data.

Description: A 15 year-old girl with obesity, OCP use, and family history of PE presented to the ED with dyspnea and chest pain after a syncopal episode at home. She was found to have massive PE affecting bilateral main PAs with evidence of right heart strain on CT-PE. She was started on heparin and non-invasive respiratory support. Soon after arrival to the ICU, she developed profound desaturations and subsequent hemodynamic collapse from near-complete occlusion of cardiac output. She was thus emergently cannulated to VA ECMO, and once stabilized was promptly taken by interventional radiology for thrombectomy.

Due to profound circulatory compromise, severity of clot burden, and bleeding complications from vascular injury sustained during cannulation, the decision was made to forgo pharmacologic thrombolysis for a mechanical approach. Pediatric IR successfully performed catheter-directed aspiration thrombectomy of bilateral PAs via Flowtriever device. The patient showed rapid stabilization and clinical improvement post-procedure, and was decannulated off ECMO within the next 24 hours. She quickly recovered and was discharged home on long-term anticoagulation.

Discussion: We describe a rare case of functional saddle PE with cor pulmonale in a pediatric patient requiring VA ECMO support where mechanical thrombectomy was safely performed, resulting in a positive outcome. Mechanical thrombectomy for PE is a technique rarely used in the pediatric population, but often used in adults with high bleeding risk or hemodynamic collapse. This technique requires skillful coordination between the proceduralist, perfusionist, and anesthesia to avoid complications (i.e. circulatory compromise, air embolism). Though rare, pediatric PE incidence is increasing and calls for more research and training in identification and management techniques.