Post-operative high-risk PE with a contraindication to thrombolysis — case discussion

Presentation

Practice case (not a real patient). A 63-year-old woman is on day 8 after an elective total knee replacement in a metropolitan Australian hospital with on-site cardiothoracic surgery, a catheter-directed PE service and an ECMO team, each with appropriate expertise and resources. She becomes acutely breathless. Her systolic blood pressure is 80-86 mmHg for 20 minutes despite adequate filling, with no arrhythmia, bleeding or sepsis; she is confused, her skin is cold and clammy, and her lactate is raised.^[1] Bedside TTE shows a dilated, hypokinetic RV, and CTPA confirms bilateral main pulmonary artery PE.^[1]

Step 1 — Name the problem

Discussion:

• She has high-risk PE: persistent hypotension with end-organ hypoperfusion meets ESC 2019 Table 4, and with PE confirmed on CTPA neither PESI nor troponin is needed to classify her.^[1]
• In AHA/ACC 2026 terms, recurrent or persistent hypotension with cardiogenic shock is Category E1, compatible with SCAI SHOCK stage C.^[3]
• ESC 2019 calls acute RV failure with low systemic output the leading cause of death in high-risk PE.^[1]

Step 2 — Support the right ventricle

• ESC 2019: anticoagulation with UFH, including a weight-adjusted bolus, is recommended without delay in high-risk PE (Class I, Level C).^[2]
• Fluid: ESC 2019 text says a modest (≤500 mL) fluid challenge can be used if central venous pressure is low, as it may increase the cardiac index, and warns that volume loading has the potential to over-distend the RV.^[1]
• Pressors: ESC 2019 says norepinephrine and/or dobutamine should be considered in high-risk PE (Class IIa, Level C); AHA/ACC 2026 recommends vasopressors and/or inotropes for cardiogenic shock due to PE (Categories D2-E2) to improve cardiac output and systemic perfusion (COR 1, LOE C-LD).^[2][3]
• Airway: AHA/ACC 2026 says deep sedation and mechanical ventilation should not be performed in Categories C-E unless clinically indicated, to avoid haemodynamic collapse (COR 3: Harm, LOE C-LD), and that vasopressors, inotropes and/or VA-ECMO should be available if sedation for intubation is needed (COR 1, LOE C-LD).^[3]

Step 3 — Choose the reperfusion

• Her knee replacement 8 days ago is major surgery within the previous 3 weeks, an absolute contraindication to fibrinolysis in ESC 2019 Table 10.^[1]
• ESC 2019: in high-risk PE with thrombolysis contraindicated, surgical pulmonary embolectomy is recommended (Class I, Level C) and percutaneous catheter-directed treatment should be considered (Class IIa, Level C), if appropriate expertise and resources are available on-site, which they are.^[2]
• AHA/ACC 2026: in Category E1, surgical embolectomy compared with anticoagulation alone (COR 2a, LOE B-NR) and MT plus anticoagulation over anticoagulation alone (COR 2a, LOE B-NR) are reasonable to prevent further clinical decompensation and acute mortality.^[3]
• The PE response team decides between the surgical and catheter options with the on-site teams; AHA/ACC 2026 recommends a PERT assessment in Categories C-E to improve in-hospital clinical care delivery (COR 1, LOE B-NR).^[3][1]

Step 4 — She deteriorates

Before the procedure starts she develops refractory cardiogenic shock (SCAI stage D) despite norepinephrine and dobutamine, without cardiac arrest.^[3]

• This is AHA/ACC 2026 Category E2; instituting VA-ECMO is reasonable, provided appropriate resources are available, to stabilise haemodynamics and improve oxygenation (COR 2a, LOE B-NR).^[3]
• ESC 2019: ECMO may be considered in combination with surgical embolectomy or catheter-directed treatment in PE with refractory circulatory collapse or cardiac arrest (Class IIb, Level C), if appropriate expertise and resources are available on-site, which they are; its text calls stand-alone ECMO with anticoagulation controversial.^[2][1]
• AHA/ACC 2026: in Category E2 not on mechanical circulatory support, surgical embolectomy is not recommended over other advanced therapies for preventing short-term mortality (COR 3: No Benefit, LOE B-NR); on VA-ECMO, the usefulness of additional advanced therapies is not well established (COR 2b, LOE C-LD).^[3]
• On VA-ECMO, AHA/ACC 2026 recommends continuing parenteral systemic anticoagulation in the absence of bleeding to prevent further thrombotic or embolic complications (COR 1, LOE B-NR).^[3]

Step 5 — After stabilisation

• ESC 2019 text: after reperfusion and haemodynamic stabilisation, patients recovering from high-risk PE can be switched to oral anticoagulation, with the timing based on clinical judgement because they were excluded from the phase III NOAC trials.^[1]
• ESC 2019 text: it remains unclear whether early thrombolysis for (intermediate- or high-risk) acute PE affects symptoms, functional limitation or CTEPH at long-term follow-up.^[1]

Examiner pitfalls

• Giving thrombolysis despite major surgery within the previous 3 weeks (an absolute contraindication in ESC 2019 Table 10).^[1]
• Intubating for convenience: AHA/ACC 2026 says deep sedation and mechanical ventilation should not be performed in Categories C-E, unless clinically indicated, to avoid haemodynamic collapse (COR 3: Harm, LOE C-LD).^[3]
• Transferring an unstable (Category E) patient to another medical centre before stabilisation (AHA/ACC 2026, COR 3: Harm, LOE C-EO).^[3]