Abstract
We report the case of a 35-year-old man who developed a massive pulmonary embolism (PE) after spine surgery. After an accidental axial fall, the patient developed a spinal epidural hematoma (SHE). Because major trauma, recent surgery and known bleeding risk are considered absolute contraindications to systemic thrombolysis, the patient was treated with catheter-directed therapy (CDT). CDT remains a useful treatment in massive PE, especially when systemic thrombolysis is contraindicated or has failed.
Highlights
- •
International guidelines have recognized the use of catheter-directed therapy (CDT) as a valid alternative treatment in massive (high-risk) PE. However, endovascular treatment of acute PE remains underused in current clinical practice.
- •
CDT could be a valid treatment, especially in difficult clinical situations
In recent years, international guidelines on the management of acute pulmonary embolism (PE) have recognized the use of catheter-directed therapy (CDT) as a valid alternative treatment in massive (high-risk) PE, especially in those patients with absolute contraindication to systemic thrombolysis or if previous thrombolytic treatment has failed . Co-existence of post-traumatic spinal epidural hematoma (SHE) and acute PE is a rare event in daily clinical practice . However, the contemporary presence of these two diseases, complicates the treatment decision making. We report the case of a 35-year-old man who was surgically treated with a partial laminectomy from T12 to L4 and evacuation of SEH after an accidental axial fall from the balcony of his home. After a week from the surgery, the patient suddenly presented arterial hypotension, dyspnea, and tachycardia. In particular, blood pressure (BP) was 90/60 mmHg while heart rate (HR) was 120 beats per minute. Standard 12-leads electrocardiogram (ECG) revealed sinus tachycardia, a typical S1-Q3-T3 pattern and an incomplete right bundle branch block (RBBB). Troponin I was 2.05 pg/ml (n.v. < 0.045) while N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) was 1256 pg/ml (n.v. < 300 pg/ml). Bedside transthoracic echocardiography (TTE) revealed moderately severe RV hypokinesis, moderate tricuspid regurgitation, and an estimated pulmonary artery systolic pressure of 50 mmHg, according to the Bernoulli’s equation. Moreover, apical four-chamber view showed a right ventricle (RV):left ventricle (LV) ratio of 1.0. Given the recent SHE the patient was considered unsuitable for standard thrombolytic treatment. For these reasons, the man was transferred to our cath-lab to be treated with CDT. Before the procedure, a blood sample was obtained in order to assess a possible thrombophilia.
Access to the right pulmonary artery was obtained through the right femoral vein using a 6 Fr pigtail. Pulmonary angiography confirmed the presence of multiple filling defects involving both the main and lobar right pulmonary arteries ( Fig. 1 A ). After sheath exchange, a 6 Fr guiding catheter was used to reach the clots, which were crossed with a 300 cm, 0.035 in wires. Then, an Angiojet® (Medrad/Bayer, MN, USA) catheter was advanced over the guidewire. The intraluminal blood clots were sucked during slow catheter passages, with substantially improvement compared to the baseline runs ( Fig. 1 B). After the endovascular treatment the patient was transferred to our intensive care cardiology unit (ICCU) where i.v. heparin infusion of 5 cm 3 /h started after 24 h from the interventional procedure. On the 1st post-interventional day, ECG showed normal sinus rhythm and the disappearance of right ventricular strain. Due to the improvement of right ventricular function and absence of deep vein thrombosis (DVT), on the 4th post-operative day the patient was re-transferred to the neurosurgery ward. Thrombophilic work-up, including evaluation of antithrombin III, mutation of factor V Leiden, methylenetetrahydrofolate reductase (MTHFR) prothrombin, protein C, protein S factor VIII and homocysteine serum levels, resulted negative. As well-known, venous thromboembolism (VTE) is a potentially life-threatening complication of both trauma and surgery . Moreover, the therapeutically management of these patients often represents a challenge, especially in those patients with previous spine surgery, due the higher risk of SHE and more in general of spine’s bleeding. In patients with previous spine surgery and VTE, any medical treatment must balance the bleeding risk and the benefit of anticoagulation. Currently, there are a lack on recommendations about the optimal treatment of these patients, especially in the acute phase of PE. To the best of our knowledge, this is the first report about the endovascular treatment of acute PE in a patient with SHE. As recommended by the latest European guidelines on acute PE, central nervous system damage, recent major trauma and known bleeding risk are absolute contraindications to the systemic thrombolytic treatment . Moreover, as we previously demonstrated, CDT could be a valid treatment, especially in difficult clinical situations . The aim of CDT in patients with acute PE is to reduce pulmonary vascular resistance and alleviate right ventricular overload, improving both cardiac output and systemic arterial pressure. Moreover, CDT allows targeted drug delivery directly into the thrombus, reducing the risk of bleeding complications, thanks a lower thrombolytic dose . As our groups evidenced in a recent survey, there is a great interest in percutaneous treatment of acute PE among interventional cardiologists, but nowadays CDT remains largely unavailable and underused . We believe that CDT and other interventional techniques, as the ultrasound accelerated thrombolysis, could represent the safer treatment, especially in difficult clinical situations where the thrombolytic treatment is contraindicated.
