Ultrasound-accelerated thrombolysis in high-risk perioperative pulmonary embolism: two case reports and review of literature

Successful cardiopulmonary resuscitation of cardiac arrest induced by massive pulmonary embolism under general anesthesia: a case report

Background

While pulmonary embolism (PE) is a common occurrence, a large life-threatening PE is not. Herein, we discuss the case of a patient with a life-threatening PE that occurred under general anesthesia.

Case presentation

We present the case of a 59-year-old male patient who was at bed rest for several days due to trauma, which resulted in femoral and rib fractures and a lung contusion. The patient was scheduled for femoral fracture reduction and internal fixation under general anesthesia. After disinfection and surgical towel laying, there was a sudden occurrence of severe PE and cardiac arrest; the patient was successfully resuscitated. Computed tomography pulmonary angiography (CTPA) was performed to confirm the diagnosis, and the patient's condition improved after thrombolytic therapy. Unfortunately, the patient's family eventually discontinued treatment.

Discussion

Massive PE frequently occurs suddenly, may endanger a patient's life at any point in time, and cannot be diagnosed quickly on the basis of clinical manifestations. Although the vital signs fluctuate greatly and there is insufficient time to conduct more tests, some factors such as special disease history, electrocardiography, end-tidal carbon dioxide, and blood gas analysis may help us determine the preliminary diagnosis; however, the final diagnosis is made using CTPA. Current treatment options include thrombectomy, thrombolysis, and early anticoagulation, of which thrombolysis and early anticoagulation are the most feasible.

Conclusion

Massive PE is a life-threatening disease that requires early diagnosis and timely treatment to save patients' lives.

Fixed-Dose Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Pulmonary Embolism Associated with COVID-19

Background. Fixed-dose ultrasound-assisted catheter-directed thrombolysis (USAT) rapidly improves hemodynamic parameters and reverses right ventricular dysfunction caused by acute pulmonary embolism (PE). The effectiveness of USAT for acute PE associated with coronavirus disease 2019 (COVID-19) is unknown. Methods and results. The study population of this cohort study consisted of 36 patients with an intermediate-high- or high-risk acute PE treated with a fixed low-dose USAT protocol (r-tPA 10–20 mg/15 h). Of these, 9 patients tested positive for COVID-19 and were age–sex-matched to 27 patients without COVID-19. The USAT protocol included, beyond the infusion of recombinant tissue plasminogen activator, anti-Xa-activity-adjusted unfractionated heparin therapy (target 0.3–0.7 U/mL). The study outcomes were the invasively measured mean pulmonary arterial pressure (mPAP) before and at completion of USAT, and the National Early Warning Score (NEWS), according to which more points indicate more severe hemodynamic impairment. Twenty-four (66.7%) patients were men; the mean age was 67 ± 14 years. Mean ± standard deviation mPAP decreased from 32.3 ± 8.3 to 22.4 ± 7.0 mmHg among COVID-19 patients and from 35.4 ± 9.7 to 24.6 ± 7.0 mmHg among unexposed, with no difference in the relative improvement between groups (p = 0.84). Within 12 h of USAT start, the median NEWS decreased from six (Q1–Q3: 4–8) to three (Q1–Q3: 2–4) points among COVID-19 patients and from four (Q1–Q3: 2–6) to two (Q1–Q3: 2–3) points among unexposed (p = 0.29). One COVID-19 patient died due to COVID-19-related complications 14 days after acute PE. No major bleeding events occurred. Conclusions. Among patients with COVID-19-associated acute PE, mPAP rapidly decreased during USAT with a concomitant progressive improvement of the NEWS. The magnitude of mPAP reduction was similar in patients with and without COVID-19.