Bilateral Pulmonary Thrombectomy and in Situ Thrombolysis in a Secondary Care Hospital: Case Report

Abstract

High-risk pulmonary embolism is a life-threatening emergency caused by acute right ventricular failure. In hemodynamically unstable patients, the lack of computed tomographic angiography in secondary health care justifies immediate invasive diagnosis and management in the cath lab.

The patient, a presenting with sudden dyspnea, chest pain, hypotension, and desaturation, showed atrial fibrillation and an S1Q3T3 pattern on the electrocardiogram, while the echocardiogram confirmed severe right ventricular dysfunction. Due to the unavailability of computed tomographic angiography at a secondary-care facility, urgent right heart catheterization was performed, revealing severe pulmonary hypertension and angiography demonstrating massive bilateral pulmonary embolism with an absence of distal flow in the right upper branch. Multiple mechanical thrombectomy passes were performed combined with low-dose in situ localized fibrinolysis using alteplase which achieved immediate angiographic improvement in anterograde flow without complications. In accordance with international cardiology guidelines, mechanical thrombectomy combined with in situ thrombolysis constitutes a highly effective and safe percutaneous rescue strategy for high-risk PE, serving as a viable therapeutic alternative in secondary health care when advanced imaging is unavailable or systemic lysis is restricted.