Postoperative Pulmonary Embolism Causing Obstructive Shock and Circulatory Collapse After Gynecologic Surgery: Successful Rescue with VA-ECMO

Abstract

Very-high-risk pulmonary embolism (PE) occurring within hours after major surgery presents a therapeutic dilemma because urgent reperfusion may be required at precisely the time when bleeding risk is greatest. We describe a 45-year-old woman who developed catastrophic bilateral PE approximately two hours after elective gynecologic surgery consisting of myomectomy and ovarian endometriotic cyst excision. Shortly after surgery, she experienced abrupt respiratory failure, profound hypotension, and rapidly progressive circulatory collapse. On arrival at a tertiary intensive care unit, arterial blood gas analysis revealed severe respiratory acidosis (pH 7.019; PaCO₂ 82 mmHg), and the patient remained unstable despite mechanical ventilation, high-dose vasopressors, and conventional resuscitative measures. Because of refractory obstructive shock and the prohibitive hemorrhagic risk associated with recent pelvic surgery, emergent venoarterial extracorporeal membrane oxygenation (VA-ECMO) was instituted before definitive radiological confirmation. Computed tomography pulmonary angiography subsequently demonstrated extensive bilateral pulmonary arterial thrombosis involving both proximal and distal branches. Management was further complicated by ongoing postoperative bleeding during mandatory anticoagulation for ECMO support, requiring repeated transfusion of blood products and frequent adjustment of anticoagulant therapy. During recovery, the patient also developed residual left popliteal deep vein thrombosis, postoperative inguinal hematoma, and surgical-site infection caused by extended-spectrum β-lactamase-producing Escherichia coli. Despite these challenges, she was successfully weaned from ECMO and mechanical ventilation, transitioned to oral rivaroxaban, and discharged without neurological sequelae. This case illustrates the complexity of managing acute PE when life-saving reperfusion strategies must be balanced against a substantial risk of postoperative bleeding. It also adds to the limited literature describing successful use of VA-ECMO as a bridge to recovery in immediate postoperative PE complicated by obstructive shock and circulatory collapse.