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• W2981064138 abstract "SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Massive pulmonary embolisms (PE) should be treated with systemic thrombolysis, but when patients are left unstable, options are limited, including open or catheter directed thrombectomy and/or catheter directed thrombolysis (CDT). We present a case where 2 doses of systemic thrombolysis and CDT were both required to achieve hemodynamic stability in a critically ill patient. CASE PRESENTATION: A 73-year-old female with endometrial carcinoma presented to the ER with shortness of breath and was found to have bilateral PEs. She suffered two PEA arrests and received two 50mg doses of Alteplase (tPA) administered systemically, in addition to continuous heparin and epinephrine infusion. Once the patient was stabilized with IVF and pressors, catheter directed tPA was attempted with partial thrombectomy restoring flow to the left lung. Despite these efforts, the following day, the patient was on maximal pressor support with phenylephrine, vasopressin, norepinephrine and epinephrine. As the patient was too unstable for transport, and not an ECMO candidate, an additional 100mg of systemic tPA was given. Following PTT normalization, CDT was restarted through the pulmonary sheath on the critical care floor. The patient was successfully weaned from pressor support over the next day. The catheter was removed after 5 days, followed by successful extubation. She was transitioned to subcutaneous enoxaparin after 9 days of heparin/bivalirudin infusion for life long anticoagulation and discharged after 20 days. DISCUSSION: This case elucidates the complexities of managing patients with massive PEs. Despite following guidelines regarding systemic thrombolysis, the patient remained unstable. The role of CDT remains unclear in current guidelines due to the paucity of randomized controlled trials. However, it is being utilized more frequently in clinical practice despite only a RV:LV ratio improvement, seen in a randomized controlled trial for intermediate risk cases of PE with hemodynamic stability, of which this patient was not (she a was high-risk PE). The complexity of this patient led to a scenario where multiple infusions were performed of both systemic and CDT. It also allowed for an observable case of two different routes of lytic therapy in tandem, extending the care far beyond any guidelines or recommendations. CONCLUSIONS: This is a unique case of massive amounts of thrombolytics, both systemically and catheter-directed, resulting in a successful outcome for a complicated and critically ill patient. It is at critical times that we move beyond the guidelines and have to make individualized treatment decisions. Giving systemic thrombolysis twice is risky from a bleeding standpoint but the patient was dying from obstructive shock requiring salvage efforts. Here we see an existing therapy used aggressively with good outcomes, perhaps shedding light on additional options of care when all else has failed. Reference #1: Hennemeyer, C., Khan, A., McGregor, H., Moffett, C., Woodhead, G. (2018). Outcomes of Catheter-Directed Therapy Plus Anticoagulation Versus Anticoagulation Alone for Submassive and Massive Pulmonary Embolism. American Journal of Medicine, 132 (2), 240-246. Reference #2: Kearon, C., Elie, A., Ornelas, J. et al. (2015). Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST, 149(2), 315-352. Reference #3: Kucher, N., Boekstegers, P., Muller OJ. et al. (2013) Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation, 129(4), 479-489. DISCLOSURES: No relevant relationships by Kyle Wilson, source=Web Response" @default.
• W2981064138 created "2019-10-25" @default.
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• W2981064138 date "2019-10-01" @default.
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• W2981064138 title "MASSIVE PULMONARY EMBOLISM SUCCESSFULLY TREATED WITH MASSIVE THERAPY: SYSTEMIC THROMBOLYSIS X 2 AND CATHETER DIRECTED THROMBOLYSIS" @default.
• W2981064138 doi "https://doi.org/10.1016/j.chest.2019.08.774" @default.
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