Vol. 42 | No. 1 | January-June 2014 Back

Open Access

Catheter-Directed Reperfusion Therapy after Unsuccessful Systemic Thrombolysis in a Patient with Evolving Sub-massive Pulmonary Embolism

Jennifer Doria-del Castillo, Josephine D. Dionisio, Jenny L. Beltran, Ariel A. Miranda
Jun 2014 DOI 10.69944/pjc.514155a40f

Abstract

Thrombolysis in sub-massive pulmonary embolism  remains controversial. We present a case of a 52 year old  obese male admitted for a 2-week history of dyspnea and  swelling of the right leg. On admission, the patient was  dyspneic and tachycardic. Venous duplex study showed  acute partially occlusive thrombosis of the right femoral  vein and totally occlusive thrombosis of the right popliteal  vein. Echocardiography revealed a dilated right ventricle  with severe pulmonary hypertension (95 mmHg). B-type  natriuretic peptide and D-dimer levels were elevated.  Computerized tomography (CT) angiogram showed a saddle  thrombus in the main pulmonary artery with almost complete  obstruction of the proximal left lower lobe segmental artery.  Systemic thrombolysis with 100 mg of recombinant tissue  plasminogen activator (r-TPA) was given, followed by low  molecular weight heparin.  

Approximately 30 hours after thrombolysis, the patient  had recurrence of dyspnea, and became hypoxemic. A  repeat CT angiogram of the pulmonary arteries revealed  an interval thinning of pulmonary embolus of the main  pulmonary artery, interlobar arteries and proximal branches,  but the obstruction of the proximal left lower lobe segmental  artery was unchanged. Right heart catheterization revealed  a pulmonary artery pressure (PAP) of 68/30 mmHg.  Pulmonary angiogram showed a large thrombus at the right  main pulmonary artery, and total occlusion of the left lower  lobe pulmonary artery. Catheter-directed thrombolysis to the  pulmonary artery was done with 50 mg of r-TPA, given over  2 hours. An inferior vena cava filter was also inserted. PAP  decreased to 50 mmHg after catheter-directed thrombolysis.  There was relief of dyspnea, and his heart rate normalized.  

This case demonstrated the safety and feasibility  of systemic thrombolysis followed by catheter-directed  thrombolysis in sub-massive pulmonary embolism and deep  venous thrombosis done in the local setting.

 

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