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Case Report
Low-dose systemic thrombolysis in patient with recent major abdominal surgery and high-risk pulmonary embolism: Case report and narrative review
1 Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
2 Department of Emergency Medicine, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, University of Milano – Statale, Milan, Italy
3 Unità Operativa Complessa Pronto Soccorso, 118 e Medicina d’Urgenza, Dipartimento Chirurgico e Grandi Traumi, Maurizio Bufalini Hospital, Cesena (FC), Italy
Address correspondence to:
Michele Domenico Spampinato
Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, St. Anna Hospital, Via A. Moro 8, Cona, Ferrara,
Italy
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Article ID: 100057Z09MS2021
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Spampinato MD, Frezza F, Nigra SG. Low-dose systemic thrombolysis in patient with recent major abdominal surgery and high-risk pulmonary embolism: Case report and narrative review. J Case Rep Images Med 2021;7:100057Z09MS2021.ABSTRACT
Introduction: Systemic thrombolysis is the treatment of choice for hemodynamically unstable patients with acute pulmonary embolism (PE) while for the intermediate-high risk ones the possibility of severe bleeding seems to outweigh the benefits. Surgical or percutaneous therapy is an option in case of contraindication/failure of fibrinolysis but they are not available in every hospital.
Case Report: An 85-year-old woman arrived at the Emergency Department for rapid onset dyspnea, thoracic pain with hypotension, tachycardia, and hypoxia. A computed tomography pulmonary angiography revealed acute PE of the main branches of the pulmonary right and left arteries. Due to hemodynamic instability and a history of recent intestinal resection surgery (25 days before), a continuous infusion of low-dose thrombolysis regimen with 50 mg rt-PA in 2 hours was started. After 30 minutes of rt-PA infusion, all vital signs were improved and at the end of rt-PA infusion. Point of care ultrasound (POCUS) revealed a reduced size of right ventricle with a decrease in right/left ventricle ratio. Hospital stay and a follow-up at two weeks revealed no complication due to the fibrinolytic administration or anticoagulant therapy.
Conclusion: Anticoagulation is still the cornerstone therapy for patients with PE, but there’s a lack of trials on reperfusion strategy. Moreover, different guidelines give different short-term risk classifications, indication, and dosage of thrombolytic drugs and absolute and relative contraindications to systemic thrombolysis. This case report shows the potential benefit of low-dose rt-PA in patients with relative contraindications to thrombolysis and presenting with vital signs compatible with hemodynamic instability.
Keywords: Emergency medicine, Point of care systems, Pulmonary embolism, Systemic thrombolysis
SUPPORTING INFORMATION
Author Contributions
Michele Domenico Spampinato - Substantial contributions to conception and design, Drafting the article, Final approval of the version to be published
Francesco Frezza - Substantial contributions to conception and design, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Stefano Geniere Nigra - Substantial contributions to conception and design, Revising it critically for important intellectual content, Final approval of the version to be published
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2021 Michele Domenico Spampinato et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
