Ultrasound-assisted catheter-directed thrombolysis for successful rescue treatment of acute pulmonary embolism in decompensated Fontan palliation.

A 22-year-old woman with complete Fontan palliation for tricuspid valve hypoplasia and chronic anemia presented to a local hospital for swelling of her left arm. Initially, the patient was hemodynamically stable without dyspnea or chest pain. Admission hemoglobin was 53 g/L and D-dimer 0.51 mg/L. Sonography showed signs of venous congestion of the left arm, but no definitive signs of venous thrombosis. Subsequently she developed dyspnea with a decrease in transcutaneous oxygen saturation to 85%. Computed tomography angiography revealed bilateral pulmonary embolism with occlusion of the right pulmonary artery. The patient was transferred to a tertiary care center. Gastroscopy detected only small stomach ulcers, and because of ongoing hemodynamic instability, the decision was to initiate rescue ultrasound-assisted catheter-directed local thrombolysis. This treatment was effective with rapid hemodynamic stabilization without bleeding complications and without residual emboli in a long-term follow-up cardiac catheterization. <Learning objective: Awareness of acute pulmonary embolism as a life-threatening condition in Fontan palliation and of ultrasound-assisted catheter-directed local thrombolysis as an effective rescue treatment option for hemodynamically unstable patients with acute pulmonary embolism and bleeding risk. Thrombosis of the subclavian vein may be missed in ultrasound examination and may also present with an admission D-dimer concentration within normal limits.>.