Successful Surgical Embolectomy for a Rapidly Deteriorating Patient with Pulmonary Embolism and Hemorrhagic Stroke.

Pulmonary embolism (PE) is a life-threatening condition. High-risk PE is defined as pulmonary embolism with either hemodynamic collapse, persistent hypotension, and/or organ hypoperfusion. The overall mortality rate associated with high-risk PE remains at approximately 30%. Intermediate-high risk PE is a new term introduced to identify hemodynamically stable PE patients with evidence of right ventricular dysfunction. Thrombolytics therapy is the first choice for treatment of high-risk PE with hemodynamic instability; however, in a patient who failed thrombolytics or have contraindication to thrombolytics, thrombus removal either with open surgical or catheter embolectomy is a good alternative. We report a case of a patient who presented with hemorrhagic stroke complicated by intermediate-high-risk PE that rapidly deteriorated before undergoing successful surgical embolectomy. Copyright:

INTRODUCTION

Pulmonary embolism (PE) and venous thromboembolism remain the third acute cardiovascular complication worldwide.[1] The annual incidence rates for PE range from 30-100 per 100,000 populations. PE is the primary cause of around 300,000 deaths per year in the United States alone.[2] Over the years, there has been an obvious trend of reduction in PE case fatality rate partially related to early detection and improved management pathways and potentially also influenced by over diagnosis of small, sub segmental, and incidental PE.[3]

The systematic management approach in PE mainly depends on rapid diagnosis, risk stratification, and initiation of proper treatment pathway based on the risk of PE and patient's comorbidity. High risk patients with hemodynamic instability are best treated with systemic thrombolysis or surgical or catheter-based embolectomy in addition to anti-coagulant therapy.

In the large remaining group of patients with PE who present without hemodynamic instability, further assessment of risk with (1) clinical risk scores, (2) presence of comorbidity, (3) laboratory indicators of organ hypoperfusion or increased right ventricular (RV) strain, and (4) imaging characteristics of RV dysfunction are recommended by European guidelines to determine the management pathway of PE patients.[4] Low risk patients can be treated safely with anti-coagulation in the outpatient setting, while intermediate and intermediate-high risk patients need in-hospital treatment with anti-coagulation and potentially thrombolysis if their clinical setting deteriorates.[567]

We present a case of a patient who presented with hemorrhagic stroke complicated by intermediate high risk PE that rapidly deteriorated before undergoing successful surgical embolectomy.

CASE PRESENTATION

A middle-aged man with a known history of hypertension presented to the hospital with acute onset of severe headache and left sided weakness. On initial examination, his blood pressure was 185/135 mmHg. The rest of his vital signs were normal. He had significant sensation loss and weakness on the entire left side. Emergent computed tomography (CT) of the head confirmed the diagnosis of right thalamic bleeding with extension to the ventricles [Figure 1].

Figure 1

Plain computed tomography head showing right-sided intracerebral hemorrhage with extension to the ventricles

The patient was admitted to the intensive care unit (ICU) and started on the appropriate management including intravenous blood pressure agents that were transitioned to oral anti-hypertensives. During the time, the patient was on pneumatic compression for deep vein thrombosis prophylaxis. On the 20th day of hospitalization, the patient developed atypical chest pain with acute shortness of breath and palpitation; he was hypoxic with oxygen saturation of 89% on room air, tachypneic with respiratory rate (RR) of 26 per minute, and tachycardi with heart rate (HR) of 135 BPM. Electrocardiogram (ECG) showed sinus tachycardia with incomplete right bundle branch block pattern [Figure 2].

Figure 2

Twelve-lead electrocardiogram showing sinus tachycardia with incomplete right bundle branch block

He also had mild increase in HS troponin at 33 ng/dl. The patient mental status was normal; his mean arterial pressure was 85 mmHg without signs of hypo perfusion. The decision to rule out pulmonary embolism was made based on the intermediate probability by Wells criteria score of 6. D-dimer was requested, and result was significantly high at 7.4 mg/L (normal 0.4 mg/L). A follow-up CT pulmonary angiogram showed large saddle embolus producing a filling defect within the main left and right pulmonary arteries [Figure 3]. Moreover, the CT showed reflux of the contrast into inferior vena cava with straightening of the interventricular septum suggesting right ventricular (RV) strain.

Figure 3

Computed tomography pulmonary angiogram showing large saddle embolus producing a filling defect within the main left and right pulmonary arteries

The patient was started immediately on unfractionated intravenous heparin. Patient was initially monitored closely in the ICU as he was hemodynamically stable despite central PE. On the next day, the patient's oxygen requirement increased to 10 liters delivered by nonrebreather mask, and he became more tachypneic. The patient's blood pressure was stable without the need of inotropic support. His blood work showed elevation in troponin level at 228 ng/L and NT-Pro BNP at 1541 pg/ml.

His transthoracic echocardiography (TTE) showed severely dilated RV, severe reduction in the RV function, moderate tricuspid regurgitation, and moderately increased pulmonary artery pressure with RV systolic pressure (RVSP) of 54 mmHg.

Multidisciplinary team decision was made to proceed with open surgical embolectomy as the patient clinical status was deteriorating, the clot burden was extensive, and systemic thrombolysis was contraindicated given the patient's recent intracranial hemorrhage.

The surgery was done by putting the patient on cardiac bypass machine, and incision was made in the main pulmonary artery and a long strand of thrombus was manually retrieved from the main, right, and left pulmonary arteries [Figure 4 and Supplemental Video 1]; then, the main pulmonary artery was sutured closed. The patient had an incidentally found patent foramen ovale on intraoperative transesophageal echocardiography (TEE) which was closed also during the surgery [Figure 5] with prolene sutures. The patient had significant clinical improvement.

Figure 4

Gross image during surgical embolectomy of large pulmonary embolism. (a) Successful manual removal of large thrombus strand through small incision in the main pulmonary artery. (b) Removed

Figure 5

Intraoperative transesophageal echocardiography with bubble injection showing bubbles leaking from right to left atrium through patent foramen ovale (blue line)

The rest of his stay in the hospital was uneventful.

He had multiple follow-up transthoracic echocardiography which showed improvement in RV size and RVSP down to 38 mmHg. Follow-up CT scan was done 4 days after the surgery and showed clearance of the saddle embolus with small residual thrombus in the right main pulmonary artery and bilateral segmental branch [Figure 6].

Figure 6

Follow-up computed tomographic pulmonary angiography showing clearance of the saddle embolus with residual small thrombus (blue arrow) in the right segmental pulmonary artery

Fourteen days post-operation, cardiac MRI was done to assess the RV function and dimension. It showed normalization of RV volume and function [Figure 7], indexed end-diastolic RV volume of 42 ml/m2, and indexed end-systolic RV volume of 22 ml/m2 with RV ejection fraction of 48%.

Figure 7

Follow-up magnetic resonance imaging showing normalization of right ventricular size and function

The patient was successfully discharged to stroke rehabilitation center at day 36. He was on oral anticoagulation (Warfarin) with goal INR of 2-3. The patient was discharged from the hospital in a stable clinical condition, he had no residual dyspnea, no bleeding complication and was followed-up in cardiology for 3 months, till the patient traveled back home.

DISCUSSION

We presented a case of intermediate–high risk PE that needed urgent open surgical embolectomy given rapid deterioration in clinical status and recent hemorrhagic stroke. The patient risk score was 100 (class III) using the original Pulmonary embolism severity index (PESI), which put him at moderate 30 days mortality risk (3.2%–7.1%).[8] Moreover, incorporating the risk score with RV dysfunction on TTE/CT scan and elevated cardiac markers increased his risk for early death even further.[9] In this group of patients, current European guidelines recommend close monitoring due to the risk of early hemodynamic instability as was done in this case.[10]

A meta-analysis of multiple thrombolysis trials, indicated a significant reduction in the combined outcome of mortality and recurrent PE in high-risk patients (defined mainly as the presence of cardiogenic shock). However, the impact of thrombolytic treatment in hemodynamically stable patients, with intermediate-risk PE was less studied. The role of thrombolysis in this group of patients was investigated in the Pulmonary Embolism Thrombolysis (PEITHO) trial.[11] The study showed low 30-day death rates overall with a significant reduction in the risk of hemodynamic decompensation or collapse with thrombolysis. However, that was at the expense of increased rates of severe extracranial and intracranial bleeding.

Another meta-analysis has suggested a reduction in PE related and overall mortality of as much as 50%–60% following thrombolytic treatment in the intermediate-risk category group.[1213] Moreover, a small randomized trial of 83 patients suggested that thrombolysis might improve functional capacity at 3 months compared with anticoagulation alone.[14] These differences are likely explained by the faster improvement in pulmonary artery obstruction, pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) and reduction in RV dilation on echocardiography, seen with thrombolytic therapy when compared with anticoagulation alone.[1516]

Open surgical embolectomy and catheter-based reperfusion were less studied when compared to thrombolysis. These modalities of treatment have the advantage of reducing bleeding risk associated with systemic thrombolysis. Catheter based reperfusion can be achieved using various modalities, most used are combination of mechanical fragmentation, ultrasound fragmentation, and in situ reduced dose thrombolysis. Most of the current knowledge on this modality of treatment was derived from pooled results from case series, with success rate reaching 87%.[17]

Further clinical studies are needed to investigate the role of these reperfusion modalities on the acute and long-term clinical outcomes of intermediate–high risk PE patients. Currently, it remains unclear whether early reperfusion therapy has an impact on clinical symptoms, functional limitation, and reduction of risk of developing chronic thromboembolic pulmonary hypertension at long-term follow-up after PE.

CONCLUSION

Open surgical embolectomy or catheter-based reperfusion can be alternative therapies when systemic thrombolysis cannot be administrated such as in case of recent intracranial hemorrhage. Further clinical studies are needed to rigorously evaluate the role of these treatment modalities on acute and long-term clinical outcomes of intermediate–high risk PE.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.