Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Introduction Percutaneous mechanical thrombectomy is a mainstay therapy in the management of high-risk acute pulmonary embolism (PE), as it reduces pulmonary artery pressure and improves right ventricular function. However, the role of percutaneous mechanical thrombectomy in the management of chronic PE or acute on chronic PE is unclear. Case Description We present the case of a 46-year-old male who presented to the emergency department with 4 days of worsening dyspnea and pleuritic chest pain. Past medical history is significant for class II obesity, prior transient ischemic attack, pulmonary hypertension with right-sided heart failure, and four admissions over the previous 10 years due to venous thromboembolic events. An inferior vena cava filter had been placed 8 years prior, and he has been maintained on long-term therapeutic anticoagulation with apixaban. However, there have been periods of time where he missed apixaban doses, including the 10 days leading up to the present admission. On presentation to the emergency department, he was mildly tachycardic and saturating 95% on 4L supplemental oxygen. Computed tomography pulmonary angiography revealed multiple bilateral pulmonary emboli with an RV:LV ratio of 1.5. Bedside point of care ultrasound also demonstrated signs of right ventricular strain. Intravenous heparin was started. Several hours later, percutaneous suction thrombectomy was performed via right femoral vein access. Pre-intervention measurements included pulmonary artery pressure 91/23mmHg (mean 51mmHg) and cardiac index 1.8L/min/m2. Both acute and chronic thrombi were removed, with post-intervention angiogram demonstrating residual distal lobar artery emboli bilaterally. Postintervention measurements included pulmonary artery pressure 98/28mmHg (mean 57mmHg) and cardiac index 1.8L/min/m2. Following the thrombectomy, the patient was requiring increasing amounts of supplemental oxygen, up to 6L per minute. Post-procedure point-of-care ultrasound was remarkable for bowing of the interventricular septum towards the left with systole, and severe right atrial enlargement. Over the next several days, clinical status including dyspnea and oxygen requirements improved with intravenous diuresis and continued anticoagulation. Patient was instructed to follow up outpatient with the pulmonary hypertension clinic with the goal of evaluating and optimizing the patient for pulmonary artery thromboendarterectomy. Discussion Chronic thromboembolic pulmonary hypertension (CTEPH) occurs when venous emboli accumulate chronically, or remain unresolved, leading to pre-capillary pulmonary hypertension and, eventually, right ventricular failure. Because CTEPH is marked by remodeling of the pulmonary vasculature and the right ventricular myocardium, there is no clear benefit to mechanical thrombectomy. Case reports of mechanical thrombectomy in chronic PE without CTEPH exist, and those patients experienced rapid improvement. However, no trials have demonstrated benefit to thrombectomy in CTEPH. The only curative treatment is pulmonary artery thromboendarterectomy.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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