Unsuccessful percutaneous mechanical thrombectomy in fibrin-rich high-risk pulmonary thromboembolism

BACKGROUND: We report a case of unsuccessful percutaneous mechanical thrombectomy in treatment of a high-risk pulmonary embolism (PE). Pulmonary thromboemboli are commonly expected as a homogenous mass, rich with red blood cell content, which respond well to percutaneous mechanical thrombectomy (PMT). Catheter-based approach or surgical embolectomy are two treatment options that are usually considered for treatment of high-risk PE when the thrombolytic therapy fails or it is contraindicated due to a patient's persisting hemodynamic compromise. Currently, selection criteria for PE treatment options are based mostly on the assessment of patient's history. The aim of this report is to highlight a possible treatment complication in PMT of structurally heterogeneous thrombotic mass due to PMT inadequacy. CASE PRESENTATION: A 32 year-old male with polytrauma was admitted to an intensive care unit after a right-sided nephrectomy and evacuation of retroperitoneal hematoma. The patient initial haemostatic disorder was improved by administration of blood preparations, an anti-fibrinolytic agent and concentrates of fibrinogen. On the third day he presented sudden onset of hemodynamic instability and was incapable of standard CTA diagnostic procedure. Urgent and relevant investigations including transthoracic and transesophageal echocardiogram confirmed a high-risk PE. PMT was performed due to contraindications for systemic thrombolysis. Long-term PMT was attempted using aspiration with several devices. No major improvement was achieved in any of the treatments and the patient died. Autopsy confirmed a large heterogeneous thrombotic mass in the pulmonary trunk folding to the right main artery. Additional histological analysis revealed a high fibrin-rich content in the peripheral surroundings of the thrombus. CONCLUSION: In the case, it was confirmed that the outcome of PMT was directly influenced by mechanical and histological features of the thromboembolus in high-risk PE. Formation of a rather complex thromboembolus in high-risk PE favors surgical embolectomy as the only life-saving treatment option. Current diagnostic imaging techniques do not enable precise assessment of thrombi structure and are therefore unable to identify patients who might benefit from PMT or open surgical embolectomy. Surgical backup treatment should be considered if there are no contraindications in the event of a failed catheter intervention.