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. 2021 Oct 18;10(1):35.
doi: 10.1186/s13741-021-00205-4.

Ultrasound-accelerated thrombolysis in high-risk perioperative pulmonary embolism: two case reports and review of literature

Götz Schmidt  1 , Fabian Edinger  2 , Christian Koch  2 , Matthias Wolff  2 , Christoph Biehl  3 , Rüdiger Hörbelt  4 , Michael Sander  2
Affiliations

Ultrasound-accelerated thrombolysis in high-risk perioperative pulmonary embolism: two case reports and review of literature

Götz Schmidt et al. Perioper Med (Lond). .

Abstract

Introduction: Treatment of high-risk pulmonary embolism (PE) in perioperative patients remains challenging. Systemic thrombolysis is associated with a high risk of major bleedings and intracranial haemorrhage. High mortality rates are reported for open pulmonary embolectomy. Therefore, postoperative surgical patients may benefit substantially from catheter-directed ultrasound-accelerated thrombolysis (USAT).

Case presentation: We report two cases of high-risk perioperative PE. Both patients developed severe haemodynamic instability leading to cardiac arrest. After the implantation of a veno-arterial extracorporeal membrane oxygenation (ECMO), they were both successfully treated with USAT. Adequate improvement of right ventricular function was achieved; thus, ECMO could be successfully weaned after 3 and 4 days, respectively. Both patients showed favourable outcomes and could be discharged to rehabilitation.

Conclusion: Current guidelines on treatment of PE offer no specific therapies for perioperative patients with high-risk PE. However, systemic thrombolysis is often excluded due to the perioperative setting and the risk of major bleeding. Catheter-directed thrombolysis was shown to utilise less thrombolytic agent while obtaining comparable thrombolytic effects. The risk for major bleeding (including intracranial haemorrhage) is also significantly lowered. Until further trials determining the value of adopted treatment strategies of high-risk PE in perioperative patients are available, USAT should be considered in similar cases.

Keywords: Embolectomy; Postoperative; Surgery; Surgical patients.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
a Apical four-chamber view showed severe RV dilatation and b parasternal short axis view revealed flattened interventricular septum (LA = left atrium, RA = right atrium, LV = left ventricle, RV = right ventricle)
Fig. 2
Fig. 2
Angiography showed bilateral occlusion of both main pulmonary arteries (* = pulmonary trunk, x = thrombotic burden)
Fig. 3
Fig. 3
Chest X-ray shows both catheters in situ (arrows)
Fig. 4
Fig. 4
CT scan revealed regredient embolic burden (x) and improved recanalization after ECMO explantation (* = pulmonary trunk, aA = ascending aorta, dA = descending aorta)
See this image and copyright information in PMC

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