Procedures: Fellow Case Report Slide: Procedures |

Endobronchial Blood Clot Extraction With Tissue Plasminogen Activator FREE TO VIEW

David Anderson, DO; Panfilo De la Cruz, MD; Jeffrey Dellavolpe, MD; Robert Walter, MD
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San Antonio Military Medical Center, Ft Sam Houston, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):996A. doi:10.1016/j.chest.2016.08.1102
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SESSION TITLE: Fellow Case Report Slide: Procedures

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 23, 2016 at 10:45 AM - 12:00 PM

INTRODUCTION: Endobronchial blood clots can present with minimal symptoms or life threatening respiratory failure. We report a successful case of removal via flexible bronchoscopy with topical use of tissue plasminogen activator (tPA) and review the associated literature. No previous reports describe such use of tPA.

CASE PRESENTATION: A 29-year-old male ejected in an MVA presented to a regional hospital and was intubated for unresponsiveness. He had cardiac arrest and underwent emergent left thoracotomy and aortic cross clamping with return of spontaneous circulation. Imaging revealed a lacerated horseshoe kidney with hemorrhage and multiple fractures. He developed worsening ARDS on maximal ventilator settings and was transferred for ECMO. On arrival, he underwent thoracic exploration, exploratory laparotomy, splenectomy, and abdominal closure. Initial flexible bronchoscopy showed no evidence of bleeding. Blood was later noted on endotracheal tube suctioning; systemic heparin for ECMO was discontinued. Flexible bronchoscopy revealed extensive tracheal clot occluding the ET tube and extending past the carina. Attempts at saline lavage, suctioning, and forceps removed small clots, but a large burden remained. Nebulized heparin was initiated to prevent further clots. tPA in 5 mL aliquots was directly applied to each clot site and allowed to settle for 24 hours, after which liquefied clot was removed via suction through the flexible bronchoscope. This process was repeated four times during his hospital course with eventual complete removal of the blood clot.

DISCUSSION: Expert opinion suggests stable patients with endobronchial clot should be managed supportively to decrease bleeding risk. Definitive management is indicated with hemodynamic instability or evidence of respiratory failure. As initial therapy, lavage, suction, and forceps extraction via flexible bronchoscopy have been favored, with moderate success. Other recommendations include rigid bronchoscopy, cryoadhesion, and topical thrombolysis using streptokinase or urokinase; tPA has not been previously reported.

CONCLUSIONS: Management of endobronchial blood clots with the use of tPA appears to be safe and effective.

Reference #1: Arney KL et al. Airway Obstruction Arising From Blood Clot: Three Reports and a Review of the Literature. Chest 1999; 115:293-300.

Reference #2: Bansal A. Streptokinase for endobronchial blood clots. Chest 1999;116(2):587

Reference #3: Cetin G et al. Removal of a Large Endobronchial Blood Clot Using a Flexible Bronchoscope. J Bronchol Intervent Pulmonol 2012;19(4):358-359

DISCLOSURE: The following authors have nothing to disclose: David Anderson, Panfilo De la Cruz, Jeffrey Dellavolpe, Robert Walter

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