The clot thickens: role of mechanical thrombectomy in intermediate to high-risk pulmonary embolism in the peri-operative setting-a case report.

BACKGROUND: European Society of Cardiology (ESC) recommends catheter-directed thrombectomy for management of high-risk pulmonary embolism (PE) with contraindications to thrombolytics or in patients that have failed thrombolytic therapy, as well as intermediate-risk PE with haemodynamic deterioration. In this case report, the role of catheter-directed mechanical thrombectomy is highlighted in the urgent peri-operative setting. CASE SUMMARY: A 71-year-old female presented with 10 days of progressive lower extremity weakness and was found to have malignant cord compression along with incidental saddle, intermediate-high-risk PE that extended to all lobes on chest computed tomography. Given the intermediate to high-risk PE with acute cor pulmonale, urgent need for surgery, and risk of haemodynamic collapse upon induction of general anaesthesia, the decision was made to proceed with urgent percutaneous treatment of the PE. Percutaneous catheter-directed thrombectomy was successfully performed. The patient returned to the intensive care unit in stable condition and was able to then receive urgent cord decompression and further treatment for malignancy with no complication. DISCUSSION: In this case, single-session thrombectomy resulted in rapid reduction of pre-operative cardiopulmonary risk by alleviating the right ventricular strain, allowing urgent cord decompression surgery to proceed with optimized haemodynamics, no bleeding events, and no further oxygen requirements. While peri-operative risk stratification for cardiovascular outcomes is well established in current guidelines, there are no clear guidelines for peri-operative risk stratification in the setting of pulmonary embolism. The importance of the multidisciplinary PE Response Team is thus emphasized, as well as the importance of continuous evaluation of clinical decompensation in PE.

Catheter-Directed Thrombectomy for Pulmonary Embolism in the Setting of Acute Stroke.

A 79-year-old male presented with an acute stroke and was treated with tissue plasminogen activator (tPA). His neurological symptoms improved, but he subsequently developed hemodynamic instability requiring intubation and vasopressors. Imaging studies revealed a massive pulmonary embolism as the cause of his worsening clinical picture. Mechanical thrombectomy using traditional devices was deemed too risky as the patient could not safely tolerate the usual anticoagulation dosage these devices require. The Penumbra Indigo® system (Alameda, CA, USA) was thus chosen for its ability to achieve thrombus aspiration within a lower therapeutic heparin range. Pulmonary artery aspiration thrombectomy was done using the device, and three days after the procedure, he was extubated and weaned completely off vasopressors. The therapy's efficacy despite the patient's unique life-threatening conditions demonstrates a novel application of the state-of-the-art pulmonary embolism treatment currently in research.