Successful Catheter‐Directed Thrombolysis for a Patient With Intermediate‐High‐Risk Pulmonary Embolism: A Case Report

TL;DR

A patient with a high-risk blood clot in the lungs was successfully treated with a targeted catheter therapy instead of risky clot-dissolving drugs.

Contribution

Demonstrates the effectiveness of catheter-directed thrombolysis in an intermediate-high-risk pulmonary embolism case with contraindications to systemic treatment.

Findings

CDT improved symptoms, oxygenation, and right ventricular function rapidly in a high-risk patient.

The patient was discharged without complications and remained stable at 3-month follow-up.

CDT is a potential safer alternative when systemic thrombolysis is not an option.

Abstract

Acute pulmonary embolism (PE) is a prevalent cardiovascular condition with significant mortality and morbidity. Treatment strategies vary according to risk stratification. While anticoagulation is sufficient for low‐risk patients, high‐risk cases often necessitate systemic thrombolysis (ST) or surgical embolectomy. Catheter‐directed therapy (CDT) has emerged as an alternative for high‐ and intermediate‐high‐risk patients, particularly when ST is contraindicated or poses a high bleeding risk. Through CDT, thrombolytic drugs are locally delivered straight into the pulmonary arteries. Despite promising outcomes in select cases, evidence for CDT remains inconclusive, reflected in its class‐IIa recommendation in current guidelines. We describe a 44‐year‐old male who experienced sudden and worsening dyspnea over 5 days. The patient had a history of smoking, methadone addiction, and a recent motor vehicle accident, with a prior intracranial hemorrhage. Echocardiography revealed right ventricular dilation and systolic dysfunction, and computed tomography pulmonary angiography confirmed massive bilateral pulmonary artery thrombosis, while the patient's troponin level was 996 ng/L (reference < 2), categorizing the patient as intermediate‐high risk. Due to contraindications to systemic thrombolysis and lack of response to anticoagulation, CDT was performed, resulting in rapid improvement in symptoms, oxygenation, and right ventricular function. The patient was discharged without complications. He was transitioned to oral anticoagulation and remained stable at three‐month follow‐up. This case highlights the potential of CDT as an effective and safe treatment for PE patients with intermediate‐to‐high risk who are not candidates for ST, a scenario with limited therapeutic options. CDT's routine use requires validation through additional studies and randomized trials.

Catheter‐directed therapy (CDT) is a viable treatment for intermediate‐high‐risk pulmonary embolism when systemic thrombolysis is contraindicated. This case highlights CDT's role in rapidly improving symptoms, oxygenation, and right ventricular function without complications, emphasizing its potential as a safer alternative that requires further validation through clinical trials.

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