Use of Multiple Treatment Modalities for Management of High-Risk Pulmonary Embolism Complicated by Clot-In-Transit

Document Type

Conference Proceeding

Publication Date

5-21-2024

Publication Title

Am J Respir Crit Care Med

Abstract

Introduction: Treatment of high-risk pulmonary Embolism (PE) is a challenging hemodynamic and logistical process. With contraindications to systemic thrombolytics, standard therapy involves choosing another treatment modality, the comparative outcomes of which are either mixed or not well studied. We present a case of a high-risk PE managed with systemic anticoagulation, catheter directed thrombolytics and mechanical embolectomy. Case Description: A 53-year-old female with uncontrolled diabetes, hypertension, peripheral arterial disease, schizoaffective disorder, and recent right leg osteomyelitis was admitted for myonecrosis of the thigh. During her hospitalization she developed tachycardia, hypoxia, and hypotension requiring vasopressors and admission to the intensive care unit (ICU). Point-of-care ultrasound (POCUS) was performed which incidentally showed inferior vena cava (IVC) and severe right ventricular (RV) dilation, and several mobile hyperechoic masses in the right atrium (RA) (Fig. 1a). Unfractionated heparin was initiated, and the Pulmonary Embolism Response Team (PERT) was activated. Computed Tomography (CT) imaging showed filling defects in the RA consistent with clots-in-transit and a large saddle pulmonary embolus (Fig. 1b) with extension to all segments of the pulmonary arteries (PA) (Fig. 1c: example of embolic burden in the right pulmonary vasculature). Systemic thrombolytics were contraindicated due to high risk of bleeding and compartment syndrome of the infected lower extremity. She underwent emergent embolectomy via AlphaVac system of RA/RV thrombus and central pulmonary arteries with an associated decline in systolic PA pressure, from 53 to 43 mmHg. With concern for distal clot, persistent shock, and consideration of bleeding risk, she received six hours of EkoSonic catheter-directed thrombolysis with rapid improvement in oxygen and vasopressor requirements. The patient was eventually discharged on warfarin pending further thrombotic workup. Follow-up echocardiogram and CT imaging showed normal hemodynamics and without any noted residual embolic disease. Discission: This case highlights a positive outcome of a high-risk PE where the rare use of multiple treatment modalities including systemic anticoagulation, catheter-directed thrombolysis, and mechanical embolectomy was required to resolve persistent obstructive shock. While current literature found a 20% mortality at 3-months in patients with PE and thrombi-intransit, use of multiple therapies allowed for complete resolution of right heart strain and pulmonary emboli at just one month after discharge (Ibrahim WH, et al. DOI:10.1177/10760296221140114). This case also demonstrates the diagnostic utility of POCUS in venous thromboembolism. Lastly, this case further demonstrates the use of a multi-disciplinary PERT program to assist in timely assessment, coordination, and intervention to reduce mortality.

Volume

209

Issue

9

First Page

A2224

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