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Case Presentation
A 65-year-old woman presents to the emergency department with acute onset of dyspnea, chest pain, and palpitations. Comorbidities include coronary artery disease, hypertension, and uterine cancer. The patient currently takes metoprolol, lisinopril, and aspirin. On examination, she is tachycardic, tachypneic, and hypoxic.
Blood pressure is 122/84 mmHg. Electrocardiogram shows sinus tachycardia. Chest X-ray shows no acute cardiopulmonary pathology. Computed tomography for pulmonary embolism shows acute pulmonary embolism.
The patient is admitted to intensive care unit for further management while being referred to interventionist for percutaneous treatment and evaluation for catheter-directed thrombolysis.
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KEY POINTS
Acute pulmonary embolism is a well-known medical condition in hospital that can result in adverse clinical outcomes. Cardiac patients are at risk of this complication due to their comorbid condition.
In addition to anticoagulation, mechanical thrombectomy devices have been introduced to analyze the benefit of clot retrieval on overall cardiopulmonary function.
Prophylaxis should be implemented to prevent thromboembolic events during or after hospitalization.
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Pulmonary embolism (PE) is one of the most common causes of death worldwide. PEs can get lodged in the pulmonary trunk, main pulmonary artery, or segmental or subsegmental branches.
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Based on the size and location of the thrombi, hemodynamic changes such as increased right heart pressures, increased pulmonary artery pressures, and decreased diffusing capacity of the lungs for carbon monoxide are seen. Saddle emboli are known to have the most severe consequences due to their size and anatomic location, which can sequentially block the right and left pulmonary arteries, leading to severe obstruction of right heart outflow tract.
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Catheter-directed thrombolysis (CDT) is one of the newest approaches for PE, and it can be more efficacious than anticoagulation alone. In addition, CDT appears to be safer than systemic thrombolysis, and procedure-related complications are very rare.
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CATHETER-DIRECTED THROMBOLYSIS
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Studies show that right-sided pressures are similar at 3 months for patients treated with CDT or with anticoagulation alone.
Given the minimal rate of procedure-related complications, CDT appears to have lower bleeding risk than systemic thrombolysis for the treatment of intermediate-risk PE.
However, there may be increased major bleeding compared with anticoagulation alone. CDT is associated with a low mortality rate (up to 4%), but the mortality rate for patients treated with anticoagulation alone is similar.
CDT not only improves clinical outcomes in patients with acute PE but also minimizes the risk of major bleeding.
Patients with acute massive and submassive PE can be managed with ultrasound-guided, catheter-directed, low-dose fibrinolysis because it decreases right ventricular (RV) dilation, pulmonary hypertension, and thrombus burden and minimizes intracranial hemorrhage.
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