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High-Risk Pulmonary Embolism with DeepVenous Thrombosis and Right AtrialThrombus in A Patient

Updated: Oct 20, 2022

Author : Irene D. Patiño, M.D High-Risk Pulmonary Embolism with Deep Venous Thrombosis and Right Atrial Thrombus in A Patient with Relative Contraindication to Systemic Thrombolysis


Case presented during Vascular Convergence last September 19, 2019

by Vascular CRFs Muriel Morilla, M.D., Irene D. Patiño, M.D., Ma. Vanessa Yu, M.D.




High-Risk Pulmonary Embolism with Deep Venous Thrombosis and Right Atrial Thrombus in A Patient with

Relative Contraindication to Systemic Thrombolysis


by Irene D. Patiño, M.D.

Philippine Heart Center


Venous thromboembolism, which includes Deep Vein thrombosis and Pulmonary Embolism, as cited by Creager et.

al.1 represents the third most common cause of cardiovascular death after myocardial infarction (MI) and strokes. We

present a case of a post-orthopedic surgery 47-year-old male who presented with dyspnea and was found out to have

deep vein thrombosis, pulmonary embolism and right atrial thrombus and subsequently responded well with half-dose

systemic thrombolysis


Case

A 47-year-old male patient, an ambulance medic, smoker, no known comorbidity, presented to the emergency room

with history of shortness of breath for 2 days. Ten days prior to admission, patient sustained right femoral fracture after

he slipped on the ground. He underwent open reduction and internal fixation of the femur 9 days prior to admission.

Post-procedure, patient remained in bed. His right leg was noted to be persistently edematous, which was attributed to

his immobility post-procedure. One day prior to admission, he had sudden onset dyspnea associated with chest

discomfort. He was brought to a local hospital and was initially hypotensive and tachycardic. Blood pressure improved

after fluid resuscitation. He was eventually transferred to our institution.

At the emergency room, the patient had the following vital signs: BP: 90/50mmHg HR: 92bpm, RR: 27 cpm afebrile and

O2 sat 98% at 1-2 LPM. On physical examination, patient was conscious, coherent, not in respiratory distress with

swelling of the right lower extremity and intact post-operative incision wound on the right thigh. Diagnostic tests were

requested. Electrocardiogram showed sinus rhythm, incomplete right bundle branch block, rule out old inferior wall

infarct. Two-Dimensional Echocardiogram revealed right atrial mass cannot rule out thrombus, dilated right ventricle

with free wall hypokinesia and depressed systolic function (RVFAC 28%), compressed left and right ventricles and

moderate pulmonary hypertension (MPAP of 45mmHg). Pulmonary embolism was then highly considered and

myocardial infarction was ruled out. Heparin bolus was given, followed by heparin drip. Further diagnostic tests were

requested, including computed tomography of the pulmonary arteries (CTPA), deep venous thrombosis (DVT)

screening of lower extremities and pro-BNP. He was also referred to Pulmonology who also requested for CTPA and

shifted IV cefepime to IV ceftazidime for pneumonia. CTPA revealed multiple filling defects are seen starting from the

main pulmonary artery and propagating to the right and left main pulmonary arteries. Scattered filling defects are also

seen in the segmental branches supplying the anterior segment of the right upper lobe, left upper and both lower lobes.

There is also infarct on the posterobasal segment of the right lower lobe. DVT screen revealed acute DVT of the right

femoral vein, popliteal vein and peroneal vein. Trop I was elevated at 0.25 ng/ml as well as the pro-BNP with a value of

2910. Baseline ABG without oxygen supplementation revealed pH 7.457 pC02 30.1 paO2 63.8 HCO3 20.9 O2sat

90.8.

With relative contraindication of a recent surgery, patient was initially scheduled for catheter-directed thrombolysis. This

was however deferred due to high risk of saddle emboli from the right atrial thrombus. He was then referred to Surgery.

Upon evaluation, they did not have any indication for surgical therapeutic intervention for the above problems. Inferior

vena cava filter was however suggested. At this time, systemic thrombolysis was being considered by the main service.

On the second hospital day, patient was admitted at the Medical Intensive Care Unit. Heparin drip was continued with

regular titration according to serial monitoring of APTT. Patient and family were advised systemic thrombolysis. They

however refused the procedure. In the meantime, Pulmonology service suggested that thrombolysis could be withheld,

as patient was already asymptomatic and had high risk for bleeding. On the fourth hospital day, Pulmonology service

suggested mechanical thrombectomy to be done by Interventional Radiology. Due to multiplicity of lesions in bilateral

pulmonary segments, and because of obstructing right atrial thrombus, procedure was not recommended. After a

consensus among Vascular specialists, the patient and family were offered systemic thrombolysis. Upon consent, and

clearance by Orthopedic Surgery, Alteplase was given half the normal dose, that is Alteplase 10mg/IV over one minute

and remaining Alteplase 40mg as infusion for 2 hours. Heparin was decreased, and serially adjusted. No significant

bleeding episodes were noted. On the sixth hospital day, heparin was discontinued and enoxaparin 0.8mL was given

subcutaneously twice daily, while waiting for the procurement of Rivaroxaban. Repeat 2D- Echocardiogram revealed

absence of right atrial thrombus, normal-sized right ventricle and improvement of the right ventricular function. On the

seventh hospital day, enoxaparin was discontinued and rivaroxaban 20mg/tab daily was started. On the ninth hospital

day, surveillance scan of the lower extremities revealed subacute DVT of right femoral vein, chronic superficial venous

thrombosis and left great saphenous vein with partial resolution and recanalization. Follow-up CTPA revealed

decrease in the number and size of the filling defects as well as decrease in the degree of pulmonary artery dilatation.

Patient was discharged stable and improved on the fourteenth day.


Discussion

Based on the existing guidelines on the management of acute pulmonary embolism, systemic thrombolytic therapy is

recommended for high-risk pulmonary embolism. However, no established guidelines exist in administering systemic

thrombolysis in a patient with right atrial thrombus and at the same time with risk of bleeding due to post-operative

condition. Recent surgery or invasive procedure is a relative contraindication to systemic thrombolysis. PEITHO trial2

showed that fibrinolytic therapy prevented hemodynamic decompensation but with increased risk of major hemorrhage

and stroke. Furthermore, instituting deep vein thrombosis prophylaxis should be considered in a patient at risk of

developing complication of venous thromboembolism to prevent major detrimental sequelae.


Conclusion

Our patient with high-risk pulmonary embolism and deep vein thrombosis with right atrial thrombus after recent

orthopedic surgery was successfully treated with half-dose systemic thrombosis without major adverse events.


References

Creager MA, Beckman JA and Localzo J. Vascular Medicine: A Companion to Braunwald's Heart Disease. 2nd Edition.

2013

Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, Bluhmki E, Bouvaist H, Brenner B,

Couturaud F, Dellas C, Empen K, Franca A, Galie N, Geibel A, Goldhaber SZ, Jimenez D, Kozak M, Kupatt C,

Kucher N, Lang IM, Lankeit M, Meneveau N, Pacouret G, Palazzini M, Petris A, Pruszczyk P, Rugolotto M, Salvi A,

Schellong S, Sebbane M, Sobkowicz B, Stefanovic BS, Thiele H, Torbicki A, Verschuren F, Konstantinides SV;

PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med

2014;370:14021411

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