Two-time systemic thromolysis with recombinant staphylokinase in a patient with massive high risk pulmonary embolism in the early postoperative period: case report

Pulmonary embolism (PE) is a leading cause of cardiovascular mortality. PE frequently complicates the postoperative course and may account for up to 0.46% of all surgical procedures. Cancer patients are at particular risk of developing postoperative PE. Among all patients with PE, approximately 5% are classified as high risk. Management of high risk postoperative PE is challenging, as it requires thrombolytic therapy, which carries an extremely high risk of hemorrhagic complications and is considered a relative contraindication. Importantly, 8% of patients with PE may experience recurrent obstructive shock following thrombolytic therapy.The 2019 European Society of Cardiology guidelines for the management of PE recommend considering alternative reperfusion strategies — catheter directed thrombolysis or surgical embolectomy — in cases of failed thrombolysis or recurrent PE; however, their use is contingent upon the immediate availability of a specialized team and equipment. When other reperfusion modalities are not feasible, repeat administration of a thrombolytic agent may be considered. This strategy is currently not standardized and is not included in existing clinical guidelines; nevertheless, in clinical practice, it is used as rescue thrombolysis in patients with persistent or recurrent hemodynamic instability. Data on its efficacy and safety remain limited and are derived predominantly from case reports and small case series.Herein, we present a clinical case of a 63 year old patient who developed high risk PE on the third day after abdominal surgery. Systemic thrombolysis with non immunogenic staphylokinase was performed, resulting in transient hemodynamic stabilization. Subsequently, the patient's condition deteriorated again with the development of obstructive shock, which was interpreted as recurrent PE. A second systemic thrombolysis with non immunogenic staphylokinase was administered, after which sustained hemodynamic stabilization, resolution of respiratory failure, and improvement in gas exchange were achieved.This clinical case is one of the first to demonstrate the feasibility of repeat thrombolytic therapy in patients with recurrent high risk PE in the early postoperative period.