(1049) Massive Pulmonary Embolism Treated With Catheter-Directed Thrombectomy Over Systemic Thrombolytic

Introduction: High-risk (massive) pulmonary embolism (PE) is defined as PE with sustained hypotension, or requiring hemodynamic support. Despite high mortality associated with massive PE, the current standard treatment is anticoagulation with systemic thrombolytics. We present a case of massive PE treated with CDT rather than systemic thrombolytics.

Description: A 36-year-old woman with a past medical history of asthma and obesity presented with shortness of breath for one day. Positive associated symptoms included lightheadedness, pleuritic chest pain, and dyspnea with minimal exertion. Patient denied leg edema, fevers, chills, and night sweats. She noted a left bunion surgery one month prior, and overall inactivity since the procedure. Home medications included a combined oral contraceptive. Positive physical exam findings included moderate distress and decreased breath sounds in all lung fields. Presenting vital signs included normotension, tachycardia, tachypnea, and hypoxemia on room air. Laboratory tests revealed elevated D-dimer, troponin, and brain-natriuretic peptide. Venous duplex did not reveal deep venous thrombosis. Chest computed tomography angiography revealed extensive pulmonary emboli within the right and left main pulmonary arteries with extension into the segmental and subsegmental arteries. Patient was initiated on intravenous (IV) heparin infusion. However, the patient became hypotensive at 76/47 mmHg and also required high flow nasal cannula. Transthoracic echocardiogram revealed right heart strain. Due to the high risk PE, emergent CDT was performed rather than systemic thrombolytic. CDT resulted in marked reduction of thrombus burden with complete resolution of hemodynamic instability. Patient was later transitioned to oral apixaban, advised to discontinue the combined oral contraceptive, and discharged on Day 3 of hospitalization.

Discussion: Mortality in massive PE remains high, suggesting anticoagulation alone may be inadequate. Our case reflects the growing evidence that suggests CDT is safe and efficacious. High quality studies are needed to potentially demonstrate improved clinical outcomes in the short-term and long-term. Such studies can ultimately change existing practice for massive PE.