BILATERAL SUBMASSIVE PULMONARY EMBOLISM WITH RIGHT FEMORAL TO POPLITEAL OCCLUSIVE DVT
Resident(s): Mitchell T. Gudmundsson, M.D., Maud M. Morshedi, M.D., Ph.D.
Attending(s): Steven C. Rose, M.D.
Program/Dept(s): Department of Radiology
Originally Posted: Month, 00, 20xx
CHIEF COMPLAINT & HPI
Chief Complaint and/or reason for consultation 55 y/o male status post syncopal episode.
History of Present Illness Walking out on a field, became short of breath and had a syncopal episode. Patient is amnestic to the event.
RELEVANT HISTORY
Past Medical History Stroke in 2003
Past Surgical History None
Family & Social History Protein C Deficiency (uncle)
Medications None
Allergies NKDA
DIAGNOSTIC WORKUP
Physical Examination Vitals: 4L Non-rebreather mask to maintain SPO2>90% Pulmonary: Clear to auscultation bilaterally but becomes short of breath and dyspneic with conversation and activities.
Laboratory Data Blood glucose 362 Negative cardiac markers Negative tox screen ABG with mild respiratory acidosis D-dimer 3500
EKG: normal sinus rhythm with PVCs
CTA OF THE CHEST
CTA OF THE CHEST - CONTINUED
DIAGNOSTIC WORK-UP QUESTION
What pulmonary artery branch is completely occluded on this initial pulmonary angiogram?
A. Right Truncus Anterior B. Left Middle Lobe C. Right Posterior Ascending D. Right Superior Segmental
SORRY, THATS INCORRECT!
What pulmonary artery branch is completely occluded on this initial pulmonary angiogram?
A. Right Truncus Anterior B. Left Middle Lobe C. Right Posterior Ascending D. Right Superior Segmental
Continue with the case
CORRECT!
What pulmonary artery branch is completely occluded on this initial pulmonary angiogram?
A. Right Truncus Anterior B. Left Middle Lobe C. Right Posterior Ascending D. Right Superior Segmental
Continue with the case
LOWER EXTREMITY DOPPLER
No Compression Compression
LOWER EXTREMITY DOPPLER - CONTINUED
No Compression Compression
DIAGNOSIS
Bilateral submassive PE with right femoral to popliteal occlusive DVT Patient started on IV heparin overnight
DIAGNOSTIC WORK-UP QUESTION
How is pulmonary arterial hypertension defined? A: Mean pulmonary arterial pressure between 10-20 mmHg B: Right ventricular hypertrophy evidenced by ECG abnormalities C: Mean pulmonary arterial pressure >25 mmHg D: Echocardiographic evidence of tricuspid regurgitation
SORRY, THATS INCORRECT!
How is pulmonary arterial hypertension defined? A: Mean pulmonary arterial pressure between 10-20 mmHg B: Right ventricular hypertrophy evidenced by ECG C: Mean pulmonary arterial pressure >25 mmHg D: Echocardiographic evidence of tricuspid regurgitation
Continue with the case
CORRECT!
How is pulmonary arterial hypertension defined? A: Mean pulmonary arterial pressure between 10-20 mmHg B: Right ventricular hypertrophy evidenced by ECG C: Mean pulmonary arterial pressure >25 mmHg D: Echocardiographic evidence of tricuspid regurgitation
Continue with the case
INTERVENTION
Decision was made to perform a catheter directed
thrombolysis
INTERVENTION
Left main pulmonary artery thrombus no longer seen with some subsegmental thrombi
Large right main pulmonary artery thrombi with no flow seen to superior lobar arteries
INTERVENTION
Mean right atrial pressure 11 mmHg concerning for right heart strain
Main pulmonary artery pressure 60/20 mean of 36 mmHg compatible with pulmonary arterial hypertension
INTERVENTION
EKOS infusion catheter placed in the right pulmonary artery.
1 mg/hr tPA infused through EKOS catheter and 500 U/hr heparin infused through the sheath. Follow up angiograms were obtained the following morning and at 48hr.
INTERVENTION QUESTION
What laboratory study is recommended to be monitored during tPA infusion? A. BNP B. INR C. Platelets D. Fibrinogen
SORRY, THATS INCORRECT!
What laboratory study is recommended to be monitored during tPA infusion? A. BNP B. INR C. Platelets D. Fibrinogen
Continue with the case
CORRECT!
What laboratory study is recommended to be monitored during tPA infusion? A. BNP B. INR C. Platelets D. Fibrinogen Levels less than 100 mg/dL have been correlated to bleeding complications.
Continue with the case
CLINICAL FOLLOW UP
Pulmonary angiogram at 48 hr following infusion Main pulmonary artery pressure 58/17 mean of 30
SUMMARY & TEACHING POINTS
Near complete EKOS ultrasound accelerated infusion catheter directed thrombolysis of bilateral submassive pulmonary emboli.
Decreased but persistent pulmonary arterial hypertension based on main pulmonary artery pressures
IVC filter also placed for prophylaxis
REFERENCES & FURTHER READING
Chamsuddin, Abbas, et al. "Catheter-directed thrombolysis with the Endowave system in the treatment of acute massive pulmonary embolism: a retrospective multicenter case series." Journal of Vascular and Interventional Radiology 19.3 (2008): 372-376.
Kuo, William T., et al. "Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques." Journal of Vascular and Interventional Radiology 20.11 (2009): 1431-1440.
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