THIRD TIME'S A CHARM: TREATING PULMONARY EMBOLISM WITH MECHANICAL THROMBECTOMY AFTER TWO FAILED ATTEMPTS WITH THROMBOLYTIC THERAPY

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary embolism (PE) can be a life-threatening condition. Massive PE, characterized by hemodynamic instability with signs of shock, comprises 4.5%-10% all PE cases and has over 50% mortality rate. When medical therapy fails, aspiration thrombectomy is treatment option for acute massive or submassive in patients compromise right ventricular (RV) dysfunction (Dopazo et al, 2018). CASE PRESENTATION: A 61-year-old male presented after an episode syncope, chest pain, dyspnea. Due to profound hypoxia, he was intubated. ECG as seen figure 1 changed from prior. Troponin 0.80. In the ED, placed on norepinephrine epinephrine due hypotension. Bedside echocardiogram (ECHO) showed enlarged RV severely reduced systolic function, hypokinetic free wall, apex. The patient subsequently developed pulseless electrical activity (PEA) arrest. Two cycles CPR were performed achieve return spontaneous circulation. possibility weight-based tPA administered. He had PEA arrest second time done 9 minutes. dose given which his hemodynamics transiently improved. Epinephrine drip discontinued, but continued. transferred ICU monitoring heparin drip. Over next 12 hours, despite multiple doses, progressively decompensated blood pressure 40mmHg while norepinephrine. Vasopressin initiated. Lactic acidosis increased 3.8 6.6 mmol/L, creatinine worsened 1.6 4.0 mg/dL, Hb 12.2 8.5 g/dL. CTA confirmed saddle pulmonary evidence strain RV/LV ratio 1.1. taken emergently cardiac catheterization vasopressors. bilateral artery T24 Inari catheter successfully, subsequent improvement hemodynamics. ECHO procedure improved function size reduction. Within 24 hours thrombectomy, vasopressors titrated off remained hemodynamically stable. DISCUSSION: Though systemic thrombolytic typically indicated unstable suspected emboli, it not effective our patient, doses. Catheter-directed therapies remove obstructive emboli directly, allowing rapid case. Furthermore, though invasive strategy, catheter-directed potential offer both short- long-term benefits thrombolysis including early recovery, risk bleeding, hypertension, reversal failure. CONCLUSIONS: techniques should considered case-by-case basis, especially who do improve thrombolysis. REFERENCE #1: 1.Ciampi-Dopazo, Juan José al. "Aspiration Thrombectomy Treatment Acute Submassive Embolism: Initial Single-Center Prospective Experience.” Journal vascular interventional radiology : JVIR vol. 29,1 (2018): 101-106. doi:10.1016/j.jvir.2017.08.010 #2: 2.Tu, Thomas "A Prospective, Single-Arm, Multicenter Trial Catheter-Directed Mechanical Intermediate-Risk FLARE Study.” JACC. Cardiovascular interventions 12,9 (2019): 859-869. doi:10.1016/j.jcin.2018.12.022 DISCLOSURES: No relevant relationships Mukul Bhattarai, source=Web Response radhika deshpande, no disclosure file Abdul Hafiz; Cameron Koester, Abhishek Kalidas Kulkarni, Mohsin Salih; Omar Siddiqui,