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BILATERAL SUBMASSIVE PULMONARY EMBOLISM WITH RIGHT FEMORAL TO POPLITEAL OCCLUSIVE DVT Resident(s): MitchellT. Gudmundsson, M.D., Maud M. Morshedi, M.D., Ph.D. Attending(s): Steven C. Rose, M.D. Program/Dept(s): Department of Radiology Originally Posted: Month, 00, 20xx

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  • BILATERAL SUBMASSIVE PULMONARY EMBOLISM WITH RIGHT FEMORAL TO POPLITEAL OCCLUSIVE DVT

    Resident(s): Mitchell T. Gudmundsson, M.D., Maud M. Morshedi, M.D., Ph.D.

    Attending(s): Steven C. Rose, M.D.

    Program/Dept(s): Department of Radiology

    Originally Posted: Month, 00, 20xx

  • CHIEF COMPLAINT & HPI

    Chief Complaint and/or reason for consultation 55 y/o male status post syncopal episode.

    History of Present Illness Walking out on a field, became short of breath and had a syncopal episode. Patient is amnestic to the event.

  • RELEVANT HISTORY

    Past Medical History Stroke in 2003

    Past Surgical History None

    Family & Social History Protein C Deficiency (uncle)

    Medications None

    Allergies NKDA

  • DIAGNOSTIC WORKUP

    Physical Examination Vitals: 4L Non-rebreather mask to maintain SPO2>90% Pulmonary: Clear to auscultation bilaterally but becomes short of breath and dyspneic with conversation and activities.

    Laboratory Data Blood glucose 362 Negative cardiac markers Negative tox screen ABG with mild respiratory acidosis D-dimer 3500

    EKG: normal sinus rhythm with PVCs

  • CTA OF THE CHEST

  • CTA OF THE CHEST - CONTINUED

  • DIAGNOSTIC WORK-UP QUESTION

    What pulmonary artery branch is completely occluded on this initial pulmonary angiogram?

    A. Right Truncus Anterior B. Left Middle Lobe C. Right Posterior Ascending D. Right Superior Segmental

  • SORRY, THATS INCORRECT!

    What pulmonary artery branch is completely occluded on this initial pulmonary angiogram?

    A. Right Truncus Anterior B. Left Middle Lobe C. Right Posterior Ascending D. Right Superior Segmental

    Continue with the case

  • CORRECT!

    What pulmonary artery branch is completely occluded on this initial pulmonary angiogram?

    A. Right Truncus Anterior B. Left Middle Lobe C. Right Posterior Ascending D. Right Superior Segmental

    Continue with the case

  • LOWER EXTREMITY DOPPLER

    No Compression Compression

  • LOWER EXTREMITY DOPPLER - CONTINUED

    No Compression Compression

  • DIAGNOSIS

    Bilateral submassive PE with right femoral to popliteal occlusive DVT Patient started on IV heparin overnight

  • DIAGNOSTIC WORK-UP QUESTION

    How is pulmonary arterial hypertension defined? A: Mean pulmonary arterial pressure between 10-20 mmHg B: Right ventricular hypertrophy evidenced by ECG abnormalities C: Mean pulmonary arterial pressure >25 mmHg D: Echocardiographic evidence of tricuspid regurgitation

  • SORRY, THATS INCORRECT!

    How is pulmonary arterial hypertension defined? A: Mean pulmonary arterial pressure between 10-20 mmHg B: Right ventricular hypertrophy evidenced by ECG C: Mean pulmonary arterial pressure >25 mmHg D: Echocardiographic evidence of tricuspid regurgitation

    Continue with the case

  • CORRECT!

    How is pulmonary arterial hypertension defined? A: Mean pulmonary arterial pressure between 10-20 mmHg B: Right ventricular hypertrophy evidenced by ECG C: Mean pulmonary arterial pressure >25 mmHg D: Echocardiographic evidence of tricuspid regurgitation

    Continue with the case

  • INTERVENTION

    Decision was made to perform a catheter directed

    thrombolysis

  • INTERVENTION

    Left main pulmonary artery thrombus no longer seen with some subsegmental thrombi

    Large right main pulmonary artery thrombi with no flow seen to superior lobar arteries

  • INTERVENTION

    Mean right atrial pressure 11 mmHg concerning for right heart strain

    Main pulmonary artery pressure 60/20 mean of 36 mmHg compatible with pulmonary arterial hypertension

  • INTERVENTION

    EKOS infusion catheter placed in the right pulmonary artery.

    1 mg/hr tPA infused through EKOS catheter and 500 U/hr heparin infused through the sheath. Follow up angiograms were obtained the following morning and at 48hr.

  • INTERVENTION QUESTION

    What laboratory study is recommended to be monitored during tPA infusion? A. BNP B. INR C. Platelets D. Fibrinogen

  • SORRY, THATS INCORRECT!

    What laboratory study is recommended to be monitored during tPA infusion? A. BNP B. INR C. Platelets D. Fibrinogen

    Continue with the case

  • CORRECT!

    What laboratory study is recommended to be monitored during tPA infusion? A. BNP B. INR C. Platelets D. Fibrinogen Levels less than 100 mg/dL have been correlated to bleeding complications.

    Continue with the case

  • CLINICAL FOLLOW UP

    Pulmonary angiogram at 48 hr following infusion Main pulmonary artery pressure 58/17 mean of 30

  • SUMMARY & TEACHING POINTS

    Near complete EKOS ultrasound accelerated infusion catheter directed thrombolysis of bilateral submassive pulmonary emboli.

    Decreased but persistent pulmonary arterial hypertension based on main pulmonary artery pressures

    IVC filter also placed for prophylaxis

  • REFERENCES & FURTHER READING

    Chamsuddin, Abbas, et al. "Catheter-directed thrombolysis with the Endowave system in the treatment of acute massive pulmonary embolism: a retrospective multicenter case series." Journal of Vascular and Interventional Radiology 19.3 (2008): 372-376.

    Kuo, William T., et al. "Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques." Journal of Vascular and Interventional Radiology 20.11 (2009): 1431-1440.