Pulmonary thromboendarterectomy successfully treated a 58-year-old male with acute on chronic pulmonary embolism after initial IR thrombectomy revealed unrecognized chronic and intracardiac thrombus.
Case Report (n=1)
No
This case highlights the importance of pre-procedural echocardiography before IR thrombectomy in acute pulmonary embolism to identify unrecognized chronic thromboembolic disease and intracardiac thrombus, which alter management and risk.
Abstract Acute on Chronic pulmonary embolism (AOCPE) results after additional embolic events superimpose on an initial pulmonary embolus that went either untreated or was incompletely treated. Chronic pulmonary embolism carries with it the risk of progressing to chronic thromboembolic pulmonary hypertension, which comes with risk of progressive heart failure. Acute pulmonary embolism is in comparison potentially acutely life threatening and often gets intervened upon as soon as discovered. A 58 year old male presented to the hospital with feeling unwell and now shortness of breath worsening over the past month, presented to the hospital due to progressive worsening of the symptoms to now intolerability. He had extensive recent travel, a prior provoked PE, and was found to have a bilateral PE on CTA-PE with cor pulmonale, atrial fibrillation with RVR, but was maintaining perfusion after intravenous rate control and IV fluid resuscitation, while closely monitored in the ICU due to risk of acute circulatory collapse secondary to pulmonary arterial trunk obstruction. He was deemed a candidate for IR thrombectomy in ED, and was to have an ECHO beforehand, but it was deferred due to the ECHO team not being able to make it in before IR was ready. During Thrombectomy, it was noted that there was adherent clot, and later ECHO revealed HFrEF, signs of caval overload, and mobile clot intraventricularly. Repeat CTA PE showed persistence of significant previously imaged obstructive thrombus as well. Suggesting the presence of acute on chronic pulmonary embolism. To treat the significant chronic clot burden, the patient would need to be transferred to a tertiary center, and transport was arranged, optimized prior to the transport with a low threshold for immediate thrombolysis for any mobile clot obstructing the pulmonary arterial trunk. The patient successfully underwent pulmonary thromboendarterectomy at tertiary center, with no uncontrolled instances of circulatory arrest. He recovered in the ICU and was eventually discharged home. The importance of this case includes several aspects. Initial treatment of his first pulmonary embolism was likely never fully completed as resolution was never verified radiographically. The risks for this patient included a large embolic burden that was at major risk of completely occluding the pre-existing hardened thrombus that most community hospitals are unable to manage. Performing IR thrombectomy without visualizing the chronic clot as well as intracardiac thrombus lead to increased risk of uncontrolled hemorrhage should complete obstruction have occurred via acute clot and required emergency thrombolytics. This abstract is funded by: none
Aceto et al. (2026) conducted a case report in Acute on Chronic pulmonary embolism (AOCPE) (n=1). IR thrombectomy and pulmonary thromboendarterectomy was evaluated. Pulmonary thromboendarterectomy successfully treated a 58-year-old male with acute on chronic pulmonary embolism after initial IR thrombectomy revealed unrecognized chronic and intracardiac thrombus.