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Although current guidelines recommend systemic thrombolysis for high-risk PTE in the absence of contraindications, this approach is associated with a significant risk of major hemorrhage and may be precluded in patients with severe comorbidities, advanced frailty, or elevated perioperative risk. Consequently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an important mechanical circulatory support strategy for this vulnerable cohort. By bypassing the obstructed pulmonary vascular bed, VA-ECMO facilitates rapid hemodynamic stabilization, mechanically unloads the strained right ventricle, and reverses systemic hypoperfusion. This review elucidates the pathophysiological rationale for right ventricular unloading in high-risk PTE and examines the evolving approach toward catheter-directed interventions and patient-tailored treatment strategies. Furthermore, we evaluate the clinical outcomes of VA-ECMO when deployed either as a stand-alone therapy bridge to recovery alongside systemic anticoagulation or as a bridge to definitive active thrombus clearance.<\/jats:p>","DOI":"10.4266\/acc.002236","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T05:50:16Z","timestamp":1787118616000},"page":"506-514","update-policy":"https:\/\/doi.org\/10.4266\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Venoarterial extracorporeal membrane oxygenation as a rescue strategy in high-risk pulmonary thromboembolism"],"prefix":"10.4266","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7421-308X","authenticated-orcid":true,"given":"Woo Jin","family":"Jang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7264-6087","authenticated-orcid":true,"given":"Ik 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