Document Type

Conference Proceeding

Publication Date

5-1-2026

Abstract

Acute pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality. The clinical outcomes are largely determined by thrombus burden and its hemodynamic impact on the right ventricle (RV). Over the past decade, catheter-directed mechanical thrombectomy has emerged as a promising alternative for systemic thrombolysis for PE management, particularly in patients at high risk for major bleeding. This approach provides rapid mechanical debulking of thrombus without exposure to thrombolytics and has been associated with significant improvements in RV function and pulmonary artery pressures. We present a case of extensive bilateral PE successfully treated with mechanical thrombectomy, highlighting the hemodynamic and symptomatic recovery achieved through this minimally invasive approach. A 77-year-old female presented to the emergency department following a syncopal episode. She appeared distressed and dyspneic. Initial assessment uncovered tachypnea, tachycardia and significant hypoxia requiring artificial supplementation. D-dimer was markedly elevated (>10,000 ng/mL). High-sensitivity troponin was elevated, consistent with acute myocardial injury. Initial EKG showed evidence of strain- T wave inversions in precordial and inferior leads, with a classic S1Q3T3 pattern. Wells score for PE was calculated at 4.5 points, corresponding to a 16.2% probability. CT Chest (PE protocol) demonstrated multiple bilateral pulmonary emboli with a saddle embolus causing near-complete obstruction of the main pulmonary arteries. Intravenous heparin was initiated promptly. Patient underwent urgent percutaneous thrombectomy due to extensive clot burden using the Inari FlowTriever system. The procedure resulted in significant improvement in pulmonary arterial flow and a reduction in mean pulmonary artery pressures from 46 mmHg to 35 mmHg. Post-procedure transthoracic echocardiography demonstrated improvement in right atrial and RV dilation, consistent with hemodynamic recovery. Clinically, the patient experienced marked improvement in dyspnea and oxygen requirements almost immediately. A hypercoagulable workup showed mildly reduced functional protein S activity. Antithrombin activity and antigen levels were also decreased; however, these findings were interpreted with caution given the presence of acute thrombosis and concurrent heparin therapy, both of which can transiently lower antithrombin levels. The remainder of the hypercoagulable evaluation, including protein C activity, factor V Leiden mutation, anticardiolipin antibodies, and antinuclear antibodies (ANA), was unremarkable. She was transitioned from heparin to apixaban and discharged in stable condition on lifelong anticoagulation. This case illustrates the role of mechanical thrombectomy in patients with intermediate-high risk PE and evidence of RV strain. These patients remain at significant risk for ventricular dysfunction and hemodynamic deterioration and must be monitored in a high acuity care setting. Catheter-directed mechanical thrombectomy can provide rapid reperfusion, reduce thrombus burden, and facilitate RV recovery resulting in immediate and sustained reductions in pulmonary artery pressures while avoiding the bleeding risk associated with systemic thrombolysis.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2026 Resident and Medical Student Day, May 1, 2026, Troy, MI

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