Fig. 1 (A) Scattered filling defects are observed in the main pulmonary arteries and their branches, predominantly in the right pulmonary artery. (B)\u00a0Placement of an inferior vena cava (IVC) filter.<\/p>\n Due to the patient\u2019s extremely critical condition, he was urgently transferred to the intensive care unit (ICU) for further life-supporting interventions following the completion of interventional procedures. Upon ICU admission, the patient was in a state of shallow coma with tachypnea. Cardiopulmonary monitoring revealed a HR of 133 beats\/min, RR of 27 breaths\/min, BP of 131\/71 mmHg (maintained with norepinephrine infusion at 0.17\u00a0\u00b5g\/kg\/min), and SpO\u2082 of 68%. Physical examination showed cyanosis of the lips, coarse bilateral lung sounds on auscultation, and arrhythmia. Emergency endotracheal intubation was performed, and invasive mechanical ventilation was initiated using synchronized intermittent mandatory ventilation (SIMV) mode (FiO\u2082 1.0, tidal volume 500 mL, RR 24 breaths\/min, PEEP 8 cmH\u2082O). Concurrently, analgesia and sedation were administered, and the norepinephrine dose was increased to 0.3\u00a0\u00b5g\/kg\/min to support hemodynamics.<\/p>\n Initial arterial blood gas analysis demonstrated severe acidosis: pH 6.95, PaO\u2082 71 mmHg, PaCO\u2082 67 mmHg, lactate 9.4 mmol\/L, base excess \u2212\u200918.3 mmol\/L. Intravenous administration of 5% sodium bicarbonate was promptly initiated to correct metabolic acidosis, resulting in an improvement of SpO\u2082 to approximately 90%. However, one hour later, SpO\u2082 declined gradually to 84%, and BP decreased to 80\/60 mmHg despite ongoing norepinephrine infusion at 0.3\u00a0\u00b5g\/kg\/min. Repeat arterial blood gas analysis showed: pH 7.23, PaO\u2082 50 mmHg, PaCO\u2082 62 mmHg, lactate 6.7 mmol\/L, HCO\u2083\u207b 26.0 mmol\/L, FiO\u2082 1.0. TTE revealed RV dilation with a right ventricle\/left ventricle ratio greater than 1 (Supplementary Video 1, Supplementary Video 2). Considering concomitant hematuria, prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT), and the high risk of systemic bleeding associated with thrombolytic therapy, the decision was made\u2014after obtaining informed consent from the patient\u2019s family\u2014to initiate emergency VA-ECMO.<\/p>\n Ultrasound-guided percutaneous cannulation was performed, including placement of a 22-French right IJV drainage catheter and a 19-French femoral artery return catheter. The tip of the drainage catheter was positioned above the hepatic vein confluence within the IVC. Real-time ultrasound guidance was used during insertion, and final catheter positioning was confirmed by chest X-ray and bedside echocardiography (Fig.\u00a02<\/a>, Supplementary Video 3). The initial ECMO flow was set at 3\u00a0L\/m\u00b2\/min. During VA-ECMO support, anticoagulation with unfractionated heparin was administered to maintain APTT between 50 and 60\u00a0s, while norepinephrine was continuously infused to maintain mean arterial pressure above 65 mmHg.<\/p>\n![\"figure](\"https:\/\/www.newsbeep.com\/il\/wp-content\/uploads\/2025\/10\/12245_2025_1021_Fig1_HTML.png\")
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