Thrombolysis for life-threatening pulmonary embolism 2 days after lung resection

Successful catheter-directed thrombolysis of a massive pulmonary embolism in a patient after recent pneumonectomy

Massive pulmonary embolism (PE) after major thoracic surgery is an uncommon but life-threatening event that is challenging to manage. At present, the treatment of acute PE is either anticoagulation with or without systemic thrombolytic therapy. We report a case of a 65-year-old female with recent left pneumonectomy who developed a massive PE. The patient was successfully and safely treated with catheter-directed thrombolysis. To our knowledge, this is the first patient treated in this fashion.

Management dilemmas in acute pulmonary embolism

Background

Physicians treating acute pulmonary embolism (PE) are faced with difficult management decisions while specific guidance from recent guidelines may be absent.

Methods

Fourteen clinical dilemmas were identified by physicians and haematologists with specific interests in acute and chronic PE. Current evidence was reviewed and a practical approach suggested.

Results

Management dilemmas discussed include: sub-massive PE, PE following recent stroke or surgery, thrombolysis dosing and use in cardiac arrest, surgical or catheter-based therapy, failure to respond to initial thrombolysis, PE in pregnancy, right atrial thrombus, role of caval filter insertion, incidental and sub-segmental PE, differentiating acute from chronic PE, early discharge and novel oral anticoagulants.

Conclusion

The suggested approaches are based on a review of the available evidence and guidelines and on our clinical experience. Management in an individual patient requires clinical assessment of risks and benefits and also depends on local availability of therapeutic interventions.

[A 49-year-old woman with deep vein thrombosis, pulmonary embolism, and left-sided paralysis]

We report the case of a 49-year-old female patient who was admitted stationary because of a left-sided paralysis which had appeared some hours before. An embolic occlusion of the right A. cerebri media turned out to be the cause. A paradoxical embolism could be assumed because of an existing deep vein thrombosis and an increased right-ventricular pressure within a hemodynamically relevant fulminant pulmonary embolism as well as the additional existence of a patent foramen ovale (PFO). Systemic lysis as treatment of the pulmonary embolism was contraindicated because slight bleeding had occurred in the area of the right basal ganglia after treatment of the embolic occlusion of the right A. cerebri media by a local lysis. Subsequently and in the acuteness, a catheter interventional PFO-closure via a double-umbrella device was placed and the pulmonary embolism was effectively treated by a local lysis through the insertion of a pigtail-catheter into the right pulmonary artery.

Successful thrombolysis after pulmonary embolectomy for persistent massive postoperative pulmonary embolism

Massive postoperative pulmonary embolism (PE) is associated with a poor prognosis in patients presenting with haemodynamic instability. Since recent surgery is a commonly accepted contraindication for thrombolytic therapy, pulmonary embolectomy is an appropriate therapeutic approach in these patients. If life-threatening symptoms of PE persist after pulmonary embolectomy, however, very few other therapeutic options are available. We report the successful use of locally administered low-dose thrombolysis 2 days after pulmonary embolectomy in a patient with postoperative PE and persistent severe hypoxaemia and pulmonary hypertension. During and after thrombolysis, no bleeding complications occurred. We conclude that low-dose thrombolysis for PE may be considered even in patients who have recently undergone major thoracic and abdominal surgery if embolectomy and continued intravenous heparin have failed to be successful and life-threatening symptoms of PE persist.

Pulmonary embolism after lung resection: diagnosis and treatment

Pulmonary embolism after lung resection (PEALR) has a high mortality rate, and it is one of the most severe complications after lung resection. Early diagnosis and treatment are essential for PEALR. Here we present 3 cases of severe PEALR. In these cases, transthoracic Doppler echocardiography was useful for confirming the diagnosis of PEALR. Thrombolysis with recombinant tissue plasminogen activator (r-tPA) was used to treat the embolism, and these patients were subsequently discharged. Thus echocardiography may become a primary procedure to confirm the diagnosis of severe PEALR, and thrombolysis with second-generation r-tPA may be the preferred choice for treatment.

Acute pulmonary thromboembolism complicating pneumonectomy: successful operative management

Pulmonary thromboembolism after pneumonectomy carries high fatality. Here we present a case of acute embolism to the left pulmonary artery with thrombus in the right atrium and inferior vena cava following right pneumonectomy. Diagnosis was made clinically and radiologically before proceeding to emergency surgery. Thromboembolectomy was successfully performed on cardiopulmonary bypass and the patient was subsequently discharged home after uneventful recovery.

Successful thrombolysis for massive pulmonary embolism after pulmonary resection

We report the successful use of thrombolysis for acute massive pulmonary embolism 2 days after right lower lobectomy for bronchial adenocarcinoma. Pulmonary angiography revealed extensive clot unsuitable for surgical embolectomy. A bolus infusion of recombinant tissue plasminogen activator produced an immediate improvement in the patient's hemodynamic state. There was substantial blood loss requiring the transfusion of 21 units of blood over the postoperative period. The patient made a successful recovery and remained well at 1 year.