Catastrophic High-Risk Pulmonary Embolism With Recurrent Cardiac Arrest Successfully Treated With Rescue Mechanical Thrombectomy After Systemic Thrombolysis

High-risk pulmonary embolism (PE) complicated by cardiac arrest carries an extremely high mortality, and the optimal rescue strategy after an inadequate response to systemic thrombolysis remains uncertain.We report the case of a 53-year-old woman with previous deep-vein thrombosis who was admitted after an outof-hospital cardiac arrest and subsequently experienced three additional episodes of cardiac arrest with pulseless electrical activity.Computed tomography pulmonary angiography demonstrated extensive bilateral central PE with severe right ventricular dilation and interventricular septal shift.Systemic thrombolysis with alteplase was administered.Despite thrombolysis and vasopressor/inotropic support, persistent cardiogenic-obstructive shock, electrical instability, and severe right ventricular pressure overload remained.Approximately 4 h after thrombolysis, rescue mechanical aspiration thrombectomy was performed using the Indigo® Aspiration System with Lightning Flash™ (Penumbra, Inc., Alameda, CA, USA).Ultrasound-guided right common femoral venous access was obtained with an 18 F sheath, and aspiration was performed in both pulmonary arteries.Pulmonary artery pressure decreased from 34 mmHg before aspiration to 25 mmHg at the end of the procedure.The patient subsequently achieved progressive hemodynamic stabilization.After prolonged mechanical ventilation and tracheostomy, neurological recovery was favorable.At discharge, echocardiography showed normal biventricular systolic function.This case illustrates that prompt escalation to rescue mechanical thrombectomy may be considered in selected patients with high-risk PE when shock, electrical instability, and right ventricular overload persist despite systemic thrombolysis.