Presentation
Massive pulmonary thromboembolism. Catheter thrombectomy this morning. On VA ECMO (Veno-arterial Extracorporeal Membrane Oxygenation). CTPA to assess clot burden.
Patient Data
The imaging shown here was the second attempt to opacify the pulmonary arteries, there was no opacification of pulmonary arteries at all on the first attempt.
Contrast is seen in the SVC, IVC, and descending aorta. There is no contrast at the aortic arch however and only a small amount of contrast in the pulmonary trunk and pulmonary arteries.
Large bilateral pulmonary emboli can be seen despite the poor contrast opacification.
Case Discussion
This case demonstrates a challenging situation of attempting to opacify the pulmonary arteries with contrast in a patient currently on ECMO. In patients on ECMO, the blood is oxygenated outside of the body and the ECMO catheters are working to bypass pulmonary circulation - clearly this means that the intravenous contrast will also mostly be bypassing the pulmonary circulation, a problem if trying to image the pulmonary arteries.
The scan is sufficient to demonstrate large bilateral pulmonary emboli but not really adequate to assess this in much detail. Perhaps a larger volume of contrast at a higher flow rate may work better but this is still likely to result in a suboptimal scan.
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