Successful systemic thrombolytic therapy for massive pulmonary embolism in a patient with breast cancer, brain metastasis, and thrombocytopenia: A case report

Successfully thrombolysis using tenecteplase in a case of massive pulmonary embolism with multiple free-floating thromboses in the right atrium and right ventricle

Massive pulmonary embolism (PE) combined with right atrial (RA) thrombus is associated with significant mortality. Hemodynamic collapses, which can manifest as hypotension, severe dyspnea; cyanosis, syncope, shock, and right ventricular heart failure are the hallmark of massive PE. Moreover, hemodynamic collapse can be the earliest clinical presentation and the most common cause of death in the first days. Although fibrinolytic therapy has contraindications; exclusion is necessary to minimize bleeding risk, but it can be lifesaving and prevent complications such as shock, right ventricular heart failure, and multi-system organ failure. Here, we report a 70-year-old woman who has an atypical presentation of sudden onset of a persistent hiccup for 8 hours diagnosed with massive pulmonary embolism with multiple free floating thromboses in the right atrial and right ventricle which has been successfully treated with systemic fibrinolytic. Furthermore, the patient was given a Tenecteplase as a last resort to save her life due to the unavailability of the catheter or surgical embolectomy besides an absolute contraindication for thrombolytic.

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Massive pulmonary embolism and associated with multiple free floating thromboses in the right atrium and right ventricle successfully treated with systemic fibrinolysis as the latest option to save a life in the presence of absolute contraindication, and this risk has exposed due to lack of availability of catheter or surgical embolectomy in our country.

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According to hemodynamic compromise of the patient resulting from the massive pulmonary embolism, the definitive treatment was pulmonary embolectomy.

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Due to the lack of availability for catheter or surgical embolectomy and other thrombolytic regimens, she became a candidate for emergent Tenecteplase administration as a last resort to save a life.

Pulmonary Embolism in the Intensive Care Unit: Therapy in Subpopulations

The optimal management of a submassive or massive pulmonary embolism (PE) during pregnancy is unclear because of a lack of large clinical trials. Evaluation of the patient who may be a candidate for more aggressive therapy includes the use of biomarkers and echocardiogram for risk stratification. PE Response teams (PERTs) have gained increasing acceptance by the medical community and are being implemented in hospitals in the United States and worldwide. PERTs bring together a team of specialists from different disciplines to enhance decision-making in the patient with acute submassive and massive PE.

Outcomes of fibrinolytic therapy for patients with metastatic cancer and acute pulmonary embolism

INTRODUCTION

Malignancy is a common cause of morbidity and mortality in the United States and around the world and the second leading cause of death in the United States. There is little data on the impact of metastatic cancer on the risk of hemorrhagic stroke or mortality among patients undergoing fibrinolytic therapy (FT) for acute PE.

METHODS

Using the National Inpatient Sample (NIS) database, we extracted admissions with a primary diagnosis of acute pulmonary embolism that underwent FT from 2010 to 2014. We performed a case control matched analysis between patients with and without metastatic cancer. Our primary outcome of interest was Mortality and our secondary outcome of interest was hemorrhagic stroke (HS).

RESULTS

Of the 883,183 patients with a primary diagnosis of acute PE between 2010 and 12014, 23,690 patients (2.7%) underwent FT. After exclusion, 22,592 patients were included in the analysis. Of these, 941 patients (4.2%) were reported to have metastatic cancer. There was a higher incidence of cerebrovascular accidents and intubation/mechanical ventilation in the metastatic cancer arm. Mortality was significantly higher in the metastatic cancer arm with no difference in the incidence of HS. In multivariate regression analysis, among all patients that underwent FT for acute PE, metastatic cancer was associated with a significant odds for mortality (OR 1.91, 95% CI 1.11-5.82, p < .001).

CONCLUSION

The presence of metastatic cancer in patients undergoing fibrinolytic therapy for acute pulmonary embolism is associated with increase mortality.

Is thrombotic event a side effect of oral buprenorphine abuse? Two case reports

Buprenorphine is used to treat opioid addiction. The spectrum of complications of oral buprenorphine is not well known. We describe two cases and based on a hypothesis is proposed which suggests that the use of oral buprenorphine could be relevant to the increase of thrombotic risk.

Rescue thrombolysis partial failure in massive PE complicated with in-transit thrombus

A 58-year-old man who presented with syncope, dyspnea, and hemodynamic compromise was found to have large free-floating right atrial thrombuses on echocardiogram. Decision was made to transfer the patient for emergent atriotomy. Cardiothoracic surgeons declared the patient as inoperable and recommended to use a lytic agent. Alteplase was administered with subsequent near-complete resolution of symptoms and near-normalization of echocardio-graphic parameters. The post-thrombolytic course was complicated by saddle pulmonary emboli requiring embolectomy. Catheter embolectomy was not available and cardiothoracic surgeon in other center considered the patient to be very high risk for transferring between hospitals and surgical intervention. Ultimately, the critical decision was made, despite the patient having been administered thrombolytic therapy within the previous 48 hours. Alteplase was given, but was not effective and the patient required surgical intervention. Surgical embolectomy was done successfully in another hospital and the patient was discharged with warfarin.