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