RECURRENT PULMONARY EMBOLISM

ABSTRACT

SESSION TITLE Variety in Risk Factors and Treatment of VTE SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: Pulmonary embolism is a very common clinical entity that health care providers face routinely. Recurrent pulmonary embolism while on anti-coagulation therapy happens in about 2 to 4% of patients, but failure of multiple modalities of anti-coagulation is unusual and should prompt a closer evaluation. In this case we present an unusual cause of anti-coagulation failure. CASE PRESENTATION A 65-year-old male patient diagnosed in 2016 with colon cancer status post hemi-colectomy and followed with CT surveillance. In 2016 he was also diagnosed with pulmonary embolism which was deemed secondary to his malignancy;this was treated with anti-coagulation for a finite duration. On surveillance CT scan in 2019 a new pulmonary embolism was diagnosed, and he was started on Apixaban therapy. In December of 2020 he was diagnosed with COVID19 which was mild to moderate in severity. A CT chest that was done at the time showed progression of the pulmonary embolism, so he was switched to low molecular weight heparin (LMWH). He presented in March of 2021 with hemoptysis and chest pain and another CT scan showed the same left pulmonary artery filling defect despite being on therapeutic LMWH. At this point we suspected an endovascular pathology, and a PET/CT scan was preformed which demonstrated an FGD positive left pulmonary artery endovascular lesion concerning for malignancy. Bronchoscopy and EBUS was done by interventional pulmonary team and biopsies from the left PA artery were taken. Pathology came back highly suspicious for angiosarcoma. The patient received chemotherapy (AIM;Adriamycin, Ifosfamide with MESNA) with an excellent response. DISCUSSION: Pulmonary artery sarcoma is a rare tumor that usually originates from the intimal layer of the pulmonary artery. It can mimic pulmonary embolism in clinical presentation and on imaging studies. In an observational analysis study published in Journal of Thoracic Disease;nearly half of 391 confirmed cases were originally misdiagnosed as pulmonary embolism. The treatment of pulmonary artery sarcoma is typically surgical intervention, although some patients may benefit from the use of chemotherapy. CONCLUSIONS: Pulmonary embolism is by far the most common cause of pulmonary artery filling defect on CT scan, typically treated with anti-coagulation with good outcomes. In the setting of therapy failure other etiologies must be considered. Although difficult to distinguish from PE, knowing the distinguishing clinical and radiologic will aid an accurate diagnosis. Reference #1 Symptoms, Diagnosis, and Therapy of Primary Sarcomas of the Pulmonary Artery. By I. Kruger, A. Borowski, M. Horst, E.R. de Vivie, W. Gross-Fengels. Thorac Cardiovasc Surg. 1990 Apr;38(2)91-5. doi 10.1055/s-2007-1014001 Reference #2 Primary pulmonary artery sarcoma a close associate of pulmonary embolism, 20-year observational analysis. Debabrata Bandyopadhyay, 1 Tanmay S. Panchabhai,2 Navkaranbir S. Bajaj,3 Pradnya D. Patil,4 and Matthew C. Bunte5 J Thorac Dis, v.8(9);2016 Sep, PMC5059338 doi 10.21037/jtd.2016.08.89 Reference #3 Al-Mehisen, Rabah et al. "Primary pulmonary artery sarcoma A rare and overlooked differential diagnosis of pulmonary embolism. Clues to diagnosis." International journal of surgery case reports vol. 65 (2019) 15-19. doi10.1016/j.ijscr.2019.10.014 DISCLOSURES No relevant relationships by Ahmad Allaham No relevant relationships by Mark Peicher