Mechanical thrombectomy of a clotted AVG in a 36-year-old male resulted in pulmonary infarction and suspected embolism (d-dimer 997 ng/mL), which improved with anticoagulation.
Case Report (n=1)
This case highlights the risk of symptomatic pulmonary embolism and infarction following mechanical thrombectomy of a clotted hemodialysis arteriovenous graft, suggesting the need for close observation and potential early anticoagulation.
Abstract Introduction Pulmonary embolism (PE) is a rare complication of arteriovenous graft (AVG) thrombosis, especially following interventions such as pharmacologic thrombolysis or mechanical thrombectomy. Case Report A 36-year-old male presented to the ED with dyspnea and right sided pleuritic chest pain. He had a pertinent medical history of ventricular septal defect repaired in infancy, , heart failure with improved ejection fraction (most recently 60%), mitral valve insufficiency that was recently repaired, end stage renal disease (ESRD) due to hypertensive nephropathy, on hemodialysis thrice weekly, via right arm AVG. 5 days before the presentation, the patient was unable to get hemodialysis because the AVG was malfunctioning due to a thrombus, treated by mechanical thrombectomy the next day and the patient received hemodialysis as usual. However, the patient developed acute right sided chest pain and dyspnea on the evening of this hemodialysis. The patient initially attributed this to volume overload and received additional hemodialysis off schedule 2 days later, but his symptoms did not improve and this made the patient present to the ED. He was found to be tachycardic, hypertensive and hypoxic to 89% on admission and required 5 liters of oxygen. Labs revealed leukocytosis, elevated BUN and creatinine, elevated Pro-BNP, elevated yet stable troponins, and elevated d-dimer to 997 ng/mL. Chest radiograph showed marked interstitial edema possibly from fluid overload. CT angiogram of the chest was performed and showed right lower lobe evolving pulmonary infarct, but no evidence for acute central or lobar pulmonary embolism, with non-diagnostic evaluation of many of the segmental and subsegmental pulmonary arteries. Given pulmonary infarction and high clinical suspicion for pulmonary embolism, heparin infusion was started. The patient also received empirical antibiotics for community-acquired pneumonia coverage, given leukocytosis. Venous duplex scan of bilateral upper and lower extremities did not reveal any venous thromboses. Repeat CT chest angiogram continued to show evolving pulmonary infarct but no obvious pulmonary emboli seen. Nevertheless, the patient’s presentation and chronology of events, is consistent with pulmonary infarction and embolism secondary to AV graft thrombosis and thrombectomy. The patient clinically improved and was discharged on renally dosed apixaban. Discussion The risk of the symptomatic PE after AVG manipulation is reported to be 5%. There have been case reports in literature with fatal PE occurring as well. Patients should be under observation post AV graft/fistula manipulation. It may be prudent to start the patient on anticoagulation as soon as AVG thrombosis is found. This abstract is funded by: None
M et al. (Fri,) conducted a case report in Pulmonary embolism and infarction (n=1). Mechanical thrombectomy was evaluated on Pulmonary embolism and infarction. Mechanical thrombectomy of a clotted AVG in a 36-year-old male resulted in pulmonary infarction and suspected embolism (d-dimer 997 ng/mL), which improved with anticoagulation.
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