Acute High Risk Pulmonary Embolism Complicated with Aortic Dissection
Presenter
Nazli K Okumus, MD, Allegheny General Hospital, Pittsburgh, PA
Nazli K Okumus, MD, Adnan Khalif, M.D., FSCAI, Tyler VanDyck, MD and Mithun Chakravarthy, M.D., Allegheny General Hospital, Pittsburgh, PA
Title
Acute High Risk Pulmonary Embolism Complicated with Aortic Dissection
Introduction
High risk pulmonary embolism (PE) is characterized as right ventricular strain on imaging or elevated cardiac biomarkers complicated with hemodynamic instability. Current data suggests mortality rates as high as 30-40% for these patients. Guidelines recommend systemic thrombolytics as first line therapy in the absence of contraindications. There is evolving data suggesting percutaneous interventions as an alternative to systemic thrombolytics and surgical approach. The concept of pulmonary embolism response team (PERT) has been expanding to allow selection of the best therapeutic approach in a case by case basis. We present the case of a patient with high risk PE that was successfully managed with percutaneous mechanical thrombectomy.
Clinical Case
69 year old female with a history of type 2 diabetes mellitus and hypertension presented to emergency room (ER) with worsening shortness of breath for 2 weeks. Her initial vital signs were within normal limits with blood pressure of 125/75 mmHg, heart rate of 75 bpm and oxygen saturation of 98% on room air. EKG was unchanged compared to baseline. Initial work up was significant with mildly elevated creatinine of 1.21, elevated pro-BNP of 12,885 pg/ml (ref 0-299 pg/ml) and high-sensitivity troponin of 18 ng/L (ref 0-14 ng/L). A CT angiogram of chest was obtained which revealed acute bilateral PE and right heart strain with left ventricle to right ventricle ratio (LV/RV) of 1.15. Bed side echocardiogram showed mild right ventricular (RV) systolic dysfunction with clot in transit. Parenteral anticoagulation was initiated and pulmonary embolism response team was activated. The decision was made to proceed with percutaneous mechanical thrombectomy with primary diagnosis of intermediate-high risk PE. While at ER, patient became hypotensive to 72/49 mmHg with new oxygen requirement. She was started on IV fluids and epinephrine drip for blood pressure and was cannulated for venoarterial extracorporeal membrane oxygenation (VA ECMO) at bedside. ER course was further complicated with cardiac arrest during initiation of ECMO flow. Subsequently, patient underwent successful percutaneous mechanical thrombectomy. VA ECMO was decannulated 3 days later. Intraprocedural transesophageal echocardiogram revealed type A aortic dissection which was followed with emergent type A aortic dissection repair. Patient was discharged on day 14 of hospitalization to a skilled nursing facility. Follow up echocardiogram after discharge showed left ventricular ejection fraction of 55%, normal right ventricular systolic function with normal pulmonary pressures.
Discussion
Acute PE is a dynamic process that requires close monitoring and repeat evaluations. Percutaneous mechanical thrombectomy is an effective alternative in patient with high risk PE. VA ECMO should be readily available in patients with acute PE who are at risk for acute decompensation. Vascular complications such as type A aortic dissection should be considered peri-procedurally as timely repair is crucial.