Acute Pulmonary Embolism: New Horizons in Cat Lab

Abstract Pulmonary embolism (PE) has an incidence of 30–100 cases per 100,000 inhabitants per year and is one of the main causes of cardiovascular mortality.The 2019 ESC guidelines suggest treating patients at intermediate–high risk with heparin, discouraging thrombolysis and leaving embolectomy to the clinician‘s judgment in case of impending hemodynamic instability. The case involves a patient with intermediate–high risk PE,and how the cardiologist‘s intuition was supported by the multidisciplinary team‘s work to ensure timely treatment. Clinical Case A 75–year–old female with systemic hypertension, recently discharged with a pneumonia diagnosis,presented to the Emergency Department complaining of dyspnea. The CT angiogram showed PE with a saddle thrombus occupying a significant portion of the main pulmonary arterial branches, severe right ventricular dilation (baseline diameter 50 mm, 44 mm RVOT average, TAPSE 16 mm),dilated vena cava; stable hemodynamics (BP 120/90 mmHg), slightly elevated troponin I (73.4 ng/L, normal range 12 ng/L), placing the patient in the intermediate–high–risk category, for which intravenous heparin was administered according to European guidelines. A follow–up CT angiogram on the fourth day showed no improvement in the radiological picture. With stable hemodynamics, indicating no systemic thrombolysis, and hypoxemia with peripheral desaturation (pO2 60 mmHg, SaO2 90%), the possibility of using pulmonary thromboaspiration was requested. On the fifth day, a pulmonary embolectomy procedure was performed via transfemoral vein (Flowtriever device).Thrombus aspiration (6 cm in length) immediately improved the baseline hemodynamic profile: PAPs pre–procedure 67 mmHg, post–procedure 43 mmHg.The follow–up CT angiogram no longer showed thrombus in the main arterial branches (remaining thrombi in segmental and subsegmental pulmonary arteries). In the pre–discharge echocardiogram, estimated PAPs was 30 mmHg, TAPSE 19 mm. Conclusions Acute pulmonary embolism still represents a clinical reality for which effective therapeutic strategies are not universally available, both for acute treatment and preventing chronic thromboembolic pulmonary hypertension.The Flowtriever device we used proved to be easy and safe to use, with immediate therapeutic results, both clinically and instrumentally.Further studies are needed to consolidate the role of percutaneous pulmonary thrombectomy in the routine treatment of patients with pulmonary embolism.