Pulmonary Vascular Disease: Student/Resident Case Report Poster - Pulmonary Vascular Disease I |

A Clinical Conundrum of Failed Thrombolyis in Pulmonary Embolism FREE TO VIEW

Rogin Subedi, MBBS; Ryan Dean, DO; Sumendra Joshi, MD; Girish Trikha, MD
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SUNY Upstate Medical University, Syracuse, NY

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

Chest. 2016;150(4_S):1212A. doi:10.1016/j.chest.2016.08.1321
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: A massive pulmonary embolism (PE) is defined as systolic blood pressure <90 mmHg or a drop in systolic blood pressure >40 mmHg for >15 minutes secondary to acute PE. Thrombolytic therapy is first-line treatment in patients with massive PE if no contraindications exist. For those who fail thrombolysis, while there are no clear guidelines in management, alternative therapies do exist, such as repeat thrombolysis and surgical embolectomy. Here we present a case of a patient with a massive PE who failed thombolytic therapy.

CASE PRESENTATION: A 43 year old male presented to the ED with sudden onset shortness of breath. He was tachycardic and hypotensive. A CTA thorax showed massive bilateral, saddle pulmonary embolism. An ECHO showed right ventricular (RV) strain with estimated pulmonary artery systolic pressure (PASP) of 53 mm Hg. He received thrombolysis with full dose tissue plasminogen activator (t-PA) with stabilization of his hemodynamics. A repeat ECHO the next day, however, failed to show any significant change. Duplex Imaging of deep veins showed clot in left femoral and right brachial vein. He was started and continued on heparin anticoagulation for five days. On the day of planned discharge, he complained of dizziness and was found to be hypotensive and tachycardic. Another ECHO showed worsening RV strain with estimated PASP of 95 mm Hg. A repeat CTA thorax showed unchanged bilateral saddle emboli without evidence of any new clots. He eventually underwent surgical embolectomy with resolution of his symptoms.

DISCUSSION: Unless contraindications exist, thrombolysis remains the first line treatment for massive PE. However, there is a dearth of information on re-evaluation of these patients after thrombolysis and treatment options if thrombolysis fails. One single center, prospective study of 488 patients compared rescue surgical embolectomy versus repeat thrombolysis in patients who failed thrombolytic therapy. They found that surgical embolectomy led to a better in-hospital course in terms of mortality, fatal bleed and recurrent PE. Though early recognition in this high risk group remains a challenge, early transthoracic ECHO to monitor RV strain post thrombolysis may identify patients at higher risk of thrombolysis failure. Further clinical studies are needed to answer these questions.

CONCLUSIONS: For patients who have failed initial systemic thrombolysis, surgical embolectomy has been shown to have a better outcome than repeat thrombolysis. Early recognition of this high risk group of patients remains a challenge.

Reference #1: Meneveau N, Séronde MF, Blonde MC, et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest. 2006;129(4):1043-50.

Reference #2: Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation. 2005;112(2):e28-32.

Reference #3: Condliffe R, Elliot CA, Hughes RJ, et al. Management dilemmas in acute pulmonary embolism. Thorax. 2014;69(2):174-80.

DISCLOSURE: The following authors have nothing to disclose: Rogin Subedi, Ryan Dean, Sumendra Joshi, Girish Trikha

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