Caution Regarding Catheter-directed Thrombolysis: Chronic Thromboembolic Pulmonary Hypertension Mistaken for Acute Submassive Pulmonary Embolism

A 40-year-old man with history of dyspnea on exertion for 6 months presented with hemoptysis. Submassive pulmonary embolism was diagnosed by computed tomography, which demonstrated occlusion of both lower lobe pulmonary arteries. His N-terminal prohormone brain natriuretic peptide was 1,691 pg/ml. Lower-extremity ultrasound revealed a nearly occlusive left common femoral vein thrombus. A transthoracic echocardiogram was notable for hypertrophied right ventricle with right ventricular systolic pressure estimated at 39 + central venous pressure mm Hg. Interventional radiology was consulted, and bilateral ultrasound-enhanced, catheter-directed thrombolysis was initiated (Figure 1A); he received 25 mg alteplase over 24 hours. There was no significant change in the angiographic appearance 18 hours after thrombolysis (Figure 1B) and no difference in pulmonary artery pressure (PAP; preintervention PAP 59/13 [28] mm Hg; postintervention PAP 59/19 [31] mm Hg). He also reported no symptomatic improvement and continued to have intermittent episodes of hemoptysis. The pulmonary thromboendarterectomy service was then contacted for evaluation, and chronic thromboembolic pulmonary hypertension (CTEPH) was diagnosed (Figure 2). He underwent pulmonary thromboendarterectomy (Figure 3) with resolution of hemoptysis and excellent hemodynamic results, with PAP 21/7 (12) mm Hg, cardiac output of 9.6 L/min, and pulmonary vascular resistance of 83 dyn ⋅ s/cm5.