Author: Saurav Uppal, MD, Additional Authors^**

See the poster presentation  |  See the poster

Introduction: Pulmonary Embolism (PE)/venous thromboembolism (VTE) is the third most frequently encountered cardiovascular syndrome behind myocardial infraction and stroke. Most patients with pulmonary embolism can be managed with anticoagulation alone, but those that have cardiovascular or respiratory compromise may require additional therapies, including thrombolysis. Thrombolytic therapy has many absolute and relative contraindications, making it difficult to offer this therapy to every patient. Catheter-assisted embolectomy offers an alternative therapy for patients with an acute PE that have a contraindication for thrombolysis.

Case Presentation: 50-year-old man with a prior history of hypertension and glioblastoma multiforme (GBM) presented to the hospital with chief complaint of shortness of breath. He had recently undergone a craniotomy with resection of his GBM about 6 weeks prior to this presentation. Computed tomography (CT) showed a saddle pulmonary embolism with evidence of right ventricular strain. He was found to be hypoxic and tachycardic on presentation. He was placed non-rebreather mask ventilation to maintain his oxygen saturation. His initial troponin I was elevated at 0.92. Therapy with parenteral heparin was initiated followed by transfer to our facility for further management. Upon transfer, his vitals showed persistent tachycardia with rates in 120s and an ongoing 100% non-rebreather mask requirement. An arterial blood gas showed hypoxemia with an arterial oxygen level of 58 mmHg and a repeat troponin I came back at 3.69. He was then placed on continuous positive airway pressure (CPAP) due to his persistent hypoxemia. A CT head was done once his partial thromboplastin time (PTT) was therapeutic and did not show any intracranial bleeding. A transthoracic echocardiogram showed normal left ventricular ejection fraction but the right ventricle was moderately enlarged with severe dysfunction. The right ventricle to left ventricle ratio calculated at 1.5:1. A lower extremity venous Doppler showed extensive deep venous thrombosis involving the bilateral femoral, popliteal, gastrocnemius, posterior tibial and peroneal veins.

Discussion/Conclusion: Neurosurgery’s input was sought regarding thrombolysis in the setting of recent intracranial surgery and was not recommended. The decision was made to pursue catheter-assisted embolectomy using a Flowtriever device. Significant clot was aspirated out of the main and right pulmonary arteries. The procedure resulted in significant improvement in his oxygenation. A retrievable inferior vena cava filter was implanted due to his extensive lower extremity clot burden. He was weaned off the oxygen over the next couple of days and transitioned from heparin to enoxaparin. He was discharged home with close follow up with the oncology team.

In challenging cases of pulmonary embolism with hemodynamic/respiratory compromise with contraindications to systemic or catheter-directed thrombolytic, catheter-assisted embolectomy offers a viable and safe option.

**Additional Authors:

Saurav Uppal, MD, The Ohio State University Wexner Medical Center

Sitaramesh Emani, MD, The Ohio State University Wexner Medical Center