B64-49 Beyond the Saddle: The Role of Catheter-Directed Thrombectomy in Intermediate-High Risk Pulmonary Embolism

Abstract Introduction Acute pulmonary embolism (PE) is a leading cause of cardiovascular mortality, with high-risk cases carrying in-hospital mortality rates up to 30%. Right ventricular (RV) strain and hemodynamic instability predict poor outcomes requiring urgent intervention. While anticoagulation and systemic thrombolysis are standard in current guidelines, catheter-directed thrombectomy (CDT) is an emerging alternative, though its use in intermediate-high risk PE is under investigation. Case Presentation A 62-year-old male with no significant medical history presented with four days of dyspnea and pleuritic chest pain. He was febrile, tachycardic, and hypoxic. Exam revealed left lower extremity (LLE) edema. Labs were notable for a mild leukocytosis, elevated B-type natriuretic peptide, and troponin with a normal lactate and creatinine clearance. Patient was initially treated for pneumonia, but persistent hypoxia and LLE findings prompted a venous duplex ultrasound, revealing an acute deep vein thrombus. ECG demonstrated the S1Q3T3 pattern. CT pulmonary angiography revealed a saddle PE with bilateral main, lobar, and segmental involvement, along with an RV/LV ratio 1.5. Echocardiography confirmed a severely dilated RV with reduced systolic function (TAPSE 1.9 cm). Despite this, he remained hemodynamically stable. Pulmonary embolism response team (PERT) was activated, and heparin drip initiated. Ongoing dyspnea and hypoxia prompted multidisciplinary discussion and subsequent CDT, yielding substantial clot extraction with improved perfusion, reduced pulmonary artery pressures, and rapid symptom improvement. (Figure 1) Repeat imaging demonstrated a decrease in clot burden and normalization of right heart function. He was discharged on extended rivaroxaban therapy for an unprovoked event. Discussion This case underscores the evolving management of intermediate-high risk PE, for which guidelines remain limited. While “saddle PE” often implies high risk, it is a radiographic descriptor that does not predict hemodynamic compromise. Our patient exhibited RV strain and persistent symptoms despite anticoagulation, prompting PERT activation and successful CDT, which is our institution’s preferred approach for select intermediate-high risk PE. This case highlights the potential efficacy and real-life application of CDT in this population, a topic that ongoing trials like PE-TRACT will further clarify. Additionally, recent data suggest that markers of hypoperfusion, such as creatinine and lactate, may enhance risk stratification, and their inclusion in future guidelines is under consideration. Our patient’s normal values reinforce the heterogeneity of presentations and the need for individualized assessment. Overall, this case supports the consideration of CDT in intermediate-high risk PE and illustrates the need for continued research and refinement of risk stratification tools in this understudied group. This abstract is funded by: None