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Paper title New interventional treatments in high-risk pulmonary embolism, evidence based?
Paper code A06
Authors
  1. Corstiaan den Uil Maasstad Ziekenhuis Speaker
Form of presentation Oral abstract presentation
Topics
  • Case report
Abstract text A 72-year-old man with no prior medical history presented to the emergency department after syncope. He was severely dyspneic and tachypneic on arrival. Four weeks earlier, he had sustained an ankle contusion while on vacation, and developed right leg swelling the day before admission.
Computed tomography pulmonary angiography (CT-PA) with coronal maximum intensity projection (MIP) reconstruction revealed filling defects in the left pulmonary artery and a large saddle pulmonary embolus (PE). An atrial septal defect (ASD) was also noted. Despite mechanical ventilation and high-dose vasopressor and inotropic support, he remained critically unstable. Systemic thrombolysis with alteplase was initiated, which failed and was followed by catheter-directed ultrasound-assisted thrombolysis (EKOS). Due to persistent hemodynamic compromise and severe hypoxemia (SpO₂ 80% on 100% FiO₂), a catheter thrombectomy was performed, with temporary veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. Respiratory and circulatory status initially improved, but the course was complicated by a malignant middle cerebral artery infarction. Following multidisciplinary discussion, care was withdrawn and the patient died.
This case illustrates the various classic treatment options in high-risk pulmonary embolism, with still high mortality. An invasive strategy like primary catheter thrombectomy may be a safer and more effective option, although this needs to be evaluated in high-quality studies.
We therefore recently started the TORPEDO-NL trial. This is the first publicly-funded randomized trial to investigate the effect of catheter-directed treatment specifically in high-risk PE patients. The trial is anticipated to play an important role in revising recommendations for high-risk PE treatment in international guidelines.