Massive pulmonary thromboembolism and catheter-directed thrombotic fragmentation in anticoagulated post-surgical patient. A cascade of events.

Abstract

Introduction: Massive pulmonary thromboembolism (PTE) is characterized by sustained arterial hypotension, cardiogenic shock, or both and presents a high in-hospital mortality. Treatment, in addition to hemodynamic and respiratory support measures, includes anticoagulation and systemic fibrinolysis. Between a third and half of patients have a contraindication to thrombolysis, mainly due to recent major surgery, and in approximately 8% of cases, it is unsuccessful. A surgical embolectomy or percutaneous treatment can be performed in selected centers in these situations.

Clinical case: 58-year-old male patient with arterial hypertension, undergoing Bentall de Bono surgery for severe aortic insufficiency. In the immediate postoperative period, he presented with hemodynamic instability associated with atrial fibrillation and signs of cardiac tamponade. Despite multiple interventions, including electrical cardioversion and pericardiocentesis, the patient developed cardiogenic shock and massive pulmonary thromboembolism, requiring mechanical ventilation and vasopressor support.

Conclusions: Percutaneous catheter-directed treatment as a reperfusion option should be considered for patients with high-risk PE where thrombolysis is contraindicated. The diagnostic strategy for suspected PE ensures timely treatment and improves the survival of these patients. A multidisciplinary team and implementing a program to treat high-risk PE are necessary.