Impact of Oral Thrombolysis After Catheter-based Thrombectomy in Acute and Subacute Submassive Pulmonary Thromboembolism

Pulmonary thromboembolism (PTE) is a relatively common cardiovascular emergency and massive PTE has always been a major source of morbidity and mortality. The traditional window period for thrombolysis in patients presenting with acute PTE is two weeks. We present a series of three patients with sub‑massive PTE, out of which two patients had acute and one patient subacute presentation. They had initially undergone catheter‑based pulmonary embolectomy and intrapulmonary thrombolysis, but there was incomplete resolution of the thrombus in all three patients 48 hours after the procedures. Subsequently, they were treated with oral thrombolytic therapy (Lumbrokinase) for 12 weeks and all the patients had complete resolution of thrombus at three months follow‑up and made a full recovery. To the best of our knowledge, the above‑mentioned novel approach combined with adjunctive oral thrombolytic therapy is being reported for the first time. A 49‑year‑old Indonesian man, hypertensive and diabetic, presented with a three‑week history of progressive dyspnea and chest pain, especially during breathing and one week history of hemoptysis prior to admission. On presentation, he was hemodynamically stable with oxygen saturation >95% on room air. The electrocardiogram (ECG) showed normal sinus rhythm. Laboratory analysis revealed a fibrin degradation test (D‑Dimer) result of 4.08 μg/ml, Troponin I 0.19 ng/ml, and NT‑ProBNP 2094 pg/ml. Computed tomography of pulmonary angiogram (CTPA) showed a large filling defect in the right pulmonary artery (PA) and a minimal filling defect in the left PA [Figure 1, pre‑procedure, case 1]. The right ventricle (RV) was dilated. Catheter‑based pulmonary thrombectomy was performed followed by intrapulmonary thrombolysis with Streptokinase for the next 10 hours. Repeat CTPA 48 hours post‑procedure (pre‑discharge) showed resolution of the thrombus in the left PA, but there was still a small thrombus in the right PA [Figure 1, pre‑discharge, case 1]. The patient was discharged with dual antiplatelet and oral thrombolytic. Two capsules of Thromboles ® China) each containing 250 mg of Lumbrokinase extract equivalent to 300,000 units of Lumbrokinase derived from an artificially cultured Lumbricus strain, were administered three times daily for 12 weeks. Follow‑up CTPA at three months showed complete resolution of the thrombus in the right PA [Figure 1, follow up three months, case 1]. A 37‑year‑old man, non‑hypertensive and non‑diabetic, presented with chest pain and dyspnea at rest for the previous one week prior to admission. He was hemodynamically stable. ECG showed sinus rhythm with T‑wave inversion in V1‑4. Laboratory results showed D‑Dimer 5 …