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COVID-19 infection complicated with acute pulmonary embolism treated with percutaneous pulmonary artery thrombectomy: a case report.

ABSTRACT:

Background

Coronavirus disease 2019 (COVID-19) disease is a highly prothrombotic state. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are observed with increased incidence in patients infected with the severe acute respiratory syndrome coronavirus 2 virus.

Case summary

A 57-year-old male patient with a recent COVID-19 infection complained of leg swelling shortly after his COVID ward discharge. A few days later he was hospitalized with acute massive PE and DVT of his left leg was diagnosed. In another facility, as the first line of treatment, the PE was managed with catheter-directed therapy (CDT) using thrombus defragmentation via 5F (French) Pigtail catheter and supraselective application of 40 mg alteplase. Following the procedure, in addition, 50 mg alteplase was also applied as a 1 hour systemic infusion. Despite the haemodynamic stabilization of the patient, he remained persistently symptomatic and tachycardic. Three days later-in our institution, a second computed tomography pulmoangiography revealed massive thrombotic masses mainly in the left pulmonary artery. Successful percutaneous thrombus aspiration was conducted. The procedure was uneventful with an immediate drop of systolic pulmonary artery pressure from 68 to 47 mmHg and relief of the patient's symptoms.

Discussion

In the era of the COVID-19 pandemic, physicians have to remain vigilant of its potential thrombotic complications, the most commonly observed being DVT and PE. We demonstrated the efficacy of percutaneous thrombus aspiration in a patient with acute COVID-19-associated PE, after initial CDT with thrombus defragmentation and high-dose tissue plasminogen activator was implemented with a suboptimal result.

SUBMITTER: Petrov I

PROVIDER: S-EPMC9214152 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundTo our knowledge we report the first case of percutaneous mechanical thrombectomy used for the treatment of massive pulmonary embolism in the United Kingdom. Pulmonary embolism is a common disease process but can be difficult to diagnose. Massive pulmonary embolism presenting with profound hypotension, however, is rare. Both phenomena carry with them significant mortality. Traditionally those patients suffering haemodynamic compromise from pulmonary embolism are treated with intravenous or catheter-directed thrombolysis. When this is contraindicated surgical embolectomy or mechanical techniques via a right heart catheter are alternative options. The former is well established but the latter is less commonly utilised in clinical practice. Our aim is to highlight the effectiveness and relative safety of percutaneous mechanical thrombectomy as a therapeutic tool in massive pulmonary embolism.Case presentationA 70 year-old gentleman presented with a 4-month history of dry cough and general malaise. Clinical examination along with routine chest radiograph confirmed a left pleural effusion which was drained. Computed tomography of the chest, abdomen and pelvis revealed a left renal mass consistent with renal cell carcinoma plus multiple metastatic subpleural nodules. Following planned thoracoscopy and pleural biopsy the patient became acutely dyspnoeic and hypotensive. Relevant investigations including computed tomography pulmonary angiogram confirmed a large saddle embolus extending in to the lobar branches of both left and right pulmonary arteries. There were several relative contraindications to thrombolysis and so the patient proceeded to have percutaneous mechanical thrombectomy with excellent results. The patient made a full recovery from the acute episode and was discharged home on warfarin with a view to planned cyto-reductive nephrectomy.ConclusionWe illustrate here that percutaneous mechanical thrombectomy can be a safe and effective method of treating massive pulmonary embolism when thrombolysis is relatively contraindicated. It may also be of use as an adjuvant therapy in those patients able to receive thrombolysis. In the future further evaluation involving a larger cohort of subjects is necessary to determine whether this treatment is superior to surgical embolectomy when thrombolysis cannot be performed.