Alteplase for Massive Pulmonary Embolism after Complicated Pericardiocentesis

Background: The occurrence of a high-risk pulmonary embolism (PE) within 48 hours of a complicated pericardiocentesis to remove a haemorrhagic pericardial effusion, is an uncommon clinical challenge. Case summary: The authors report the case of a 75-year-old woman who presented with signs of imminent cardiac tamponade due to recurring idiopathic pericardial effusion. The patient underwent pericardiocentesis that was complicated by the loss of 1.5 litres of blood. Within 48 hours, the patient had collapsed with clear signs of obstructive shock. This was a life-threating situation so alteplase was administered after cardiac tamponade and hypertensive pneumothorax had been excluded. CT chest angiography later confirmed bilateral PE. The patient achieved haemodynamic stability less than an hour after receiving the alteplase. However, due to the high risk of bleeding, the medical team suspended the thrombolysis protocol and switched to unfractionated heparin within the hour. The cause of the PE was not identified despite extensive study, but after 1 year of follow-up the patient remained asymptomatic. Discussion: Despite the presence of a contraindication, the use of thrombolytic therapy in obstructive shock after exclusion of hypertensive pneumothorax can be life-saving, and low-dose thrombolytic therapy may be a valid option in such cases.

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Thrombolytic therapy for pulmonary embolism: lessons from recent clinical trials

Australasian Journal of Paramedicine ◽

10.33151/ajp.3.4.341 ◽

2015 ◽

Vol 3 (4) ◽

Author(s):

Lexin Wang

Keyword(s):

Pulmonary Embolism ◽

Thrombolytic Therapy ◽

Clinical Studies ◽

Massive Pulmonary Embolism ◽

Common Disease ◽

Thrombolytic Treatment ◽

Normal Blood Pressure ◽

Life Saving ◽

Submassive Pulmonary Embolism

Pulmonary embolism is a common disease that is associated with significant mobility and mortality. Thrombolysis is potentially life saving when used in conjunction with anticoagulant therapy. Indications for thrombolysis for pulmonary embolism are not well defined. In patients with acute massive pulmonary embolism and hypotension, thrombolytic therapy offers some benefits in terms of mortality reduction. The use of thrombolysis in patients with stable haemodynamics has been controversial for more than two decades. Recent clinical studies have indicated that thrombolytic treatment in conjunction with heparin in patients with submassive pulmonary embolism and normal blood pressure can prevent deterioration of the disease and diminish the need for more intensive therapies during hospitalisation. The role of prehospital thrombolytic therapy for acute pulmonary embolism is unclear and further clinical studies are warranted.

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P27 Long term follow-up after thrombolytic therapy in acute massive pulmonary embolism: Results from the step 2 trial

Fibrinolysis and Proteolysis ◽

10.1016/s0268-9499(98)80335-4 ◽

1998 ◽

Vol 12 ◽

pp. 99

Keyword(s):

Pulmonary Embolism ◽

Thrombolytic Therapy ◽

Massive Pulmonary Embolism ◽

Long Term Follow Up

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The Analysis of Long-Term Results and Quality of Life in Patients with Massive Pulmonary Embolism in the Course of Treatment with Thrombolytic and Anticoagulant Drugs

Russian Sklifosovsky Journal Emergency Medical Care ◽

10.23934/2223-9022-2019-8-3-274-278 ◽

2019 ◽

Vol 8 (3) ◽

pp. 274-278

Author(s):

A. G. Pronin

Keyword(s):

Quality Of Life ◽

Pulmonary Embolism ◽

Pulmonary Hypertension ◽

High Risk ◽

Thrombolytic Therapy ◽

Early Death ◽

Massive Pulmonary Embolism ◽

Long Term Results

Relevance Chronic post-embolic pulmonary hypertension (CPEPH) is a complication of pulmonary thromboembolism found almost in every 10th patient. A special risk group consists of patients with a moderately high risk of pulmonary embolism associated death according to stratification of the probability of early death of the European Society of Cardiology. The development of this condition is potentially preventable with timely and adequate therapy in these patients. We have improved the approach to the treatment of pulmonary embolism patients, which allows indications for thrombolytic therapy to be clarified and expanded. The aim of the study is to evaluate its effectiveness in the long-term period, as well as analyze the qualities of life of patients with massive pulmonary embolism, who underwent thrombolytic and anticoagulant therapy.Material and methods The treatment, as well as the analysis of long-term results and quality of life of 71 patients aged 29 to 88 years with diagnosed pulmonary embolism with a moderately high risk of early death were performed. All patients underwent general clinical and biochemical blood tests, D-dimer, ECG, echocardiography, ultrasound of the lower extremities veins, CT angiopulmonography. We registered the dynamics of echocardiographic symptoms of the right heart overload over 6 months (right ventricle size, pulmonary hypertension, the degree of tricuspid regurgitation), and assessed the quality of life based on a survey with the establishment of the appearance of shortness of breath, tachycardia, hospitalizations for heart failure during the study period. Depending on the type of therapy, the patients were divided into two groups: 38 patients with thrombolytic therapy and 33 patients with anticoagulant therapy. Subsequently, their comparative analysis was carried out.Results and conclusion In patients with pulmonary embolism of moderately high risk of early death, who underwent thrombolytic therapy, chronic postembolic pulmonary hypertension developed 2.9 times less and a higher quality of life retained in these patients than in patients treated with anticoagulant drugs.

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Thrombolytic therapy with alteplase and recombinant prourokinase in massive pulmonary embolism

Clinical Medicine (Russian Journal) ◽

10.30629/0023-2149-2021-99-3-177-186 ◽

2021 ◽

Vol 99 (3) ◽

pp. 177-186

Author(s):

Yu. V Ovchinnikov ◽

M. V. Zelenov ◽

V. S. Polovinka ◽

E. V. Kryukov

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Thrombolytic Therapy ◽

Massive Pulmonary Embolism ◽

Risk Of Death ◽

Results Of Treatment ◽

Observation Period

Analysis of clinical effi cacy and safety of alteplase and recombinant prourokinase in 82 patients with pulmonary embolism (PE) of high and intermediate high risk of death during the hospital observation period, whо were divided into two groups depending on the thrombolytic applied: the 1st group — recombinant prourokinase (40 people), the 2nd group — alteplase (42 people). The results of treatment, indicators of eff ectiveness and safety of thrombolytic therapy with alteplase and recombinant prourokinase were analyzed. The eff ectiveness and safety of thrombolytic therapy, evaluated clinically and instrumentally, did not diff er in the use of the drugs studied. However, at the time of development of PE from 5 to 14 days from the onset of the disease, for thrombolysis, it is preferable to use recombinant prourokinase, as it leads to a more signifi cant reduction in the volume of thrombotic masses than with the use of alteplase.

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Low-dose urokinase thrombolytic therapy for patients with acute intermediate-high-risk pulmonary embolism: A retrospective cohort study

PLoS ONE ◽

10.1371/journal.pone.0248603 ◽

2021 ◽

Vol 16 (3) ◽

pp. e0248603

Author(s):

Cuilian Weng ◽

Xincai Wang ◽

Long Huang ◽

Xingsheng Lin ◽

Qinghua Liu

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Thrombolytic Therapy ◽

Anticoagulant Therapy ◽

Low Dose ◽

Therapy Group ◽

Minor Bleeding ◽

Short Term

Introduction Patients at intermediate-high risk of developing a pulmonary embolism (PE) are very likely to experience adverse outcomes, such as cardiovascular instability and death. The role of thrombolytic therapy in intermediate-high-risk PE remains controversial. Objectives This study aimed to determine the efficacy and safety of low-dose urokinase (UK) thrombolytic therapy for intermediate-high-risk PE. Patients and methods This retrospective study included 81 consecutive patients with intermediate-high-risk PE from two centers. Patients received low-dose UK or low-molecular-weight heparin (anticoagulant therapy group). The efficacy outcomes were mortality, computed tomography pulmonary angiography (CTPA)-confirmed absorption, and dyspnea. Safety was assessed as the incidence of bleedings. Results The in-hospital mortality, 9-month mortality, and long-term mortality at the last follow-up were comparable for the low-dose UK group and the anticoagulant therapy group (6.45% vs. 0%, p = 0.144, 9.68% vs. 8.16%, p = 0.815, and 12.90% vs. 12.24%, p = 0.931, respectively). CTPA-confirmed absorption at one month after admission was higher in the low-dose UK group than in the anticoagulant therapy group (p = 0.016). The incidences of short-term dyspnea at discharge and long-term dyspnea at the last follow-up were lower in the low-dose UK group than in the anticoagulant therapy group (27.59% vs. 52%, p = 0.035, 33.33% vs. 58.14%, p = 0.043, respectively). No major bleeding occurred. The incidence of minor bleeding was not significantly different between the two groups (3.23% vs. 6%, p = 0.974). Conclusion In intermediate-high-risk PE, a low-dose UK might increase CTPA-confirmed absorption and improve short-term and long-term dyspnea without affecting mortality or increasing the bleeding risk.

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The Results of Thrombolytic Treatment in Patients With High-risk Pulmonary Embolism

Journal Of Cardiovascular Emergencies ◽

10.2478/jce-2019-0013 ◽

2019 ◽

Vol 5 (3) ◽

pp. 92-98

Author(s):

Ali Ekber Atas ◽

Atilla Sarac ◽

Adem Dirican ◽

Nazlı Topbası ◽

Tugce Uzar ◽

...

Keyword(s):

Pulmonary Embolism ◽

Thrombolytic Therapy ◽

Cardiopulmonary Arrest ◽

Clinical Status ◽

Massive Pulmonary Embolism ◽

Pulmonary Medicine ◽

Thrombolytic Treatment ◽

Life Saving ◽

Key Indicators ◽

Overall Mortality

Abstract Background: Mortality rates due to massive pulmonary embolism (PE) are much higher than estimated. Although thrombolytic therapy is controversial, it can be a life-saving procedure and can be safely used in patients with massive PE. Study aim: We aimed to share the results of thrombolytic treatment in patients with massive PE. Material and methods: We retrospectively evaluated 72 patients with PE admitted between January 2010 and April 2018 to the Department of Pulmonary Medicine, VM Medicalpark Samsun Hospital, Samsun, Turkey. The data of patients who received thrombolytic treatment were retrospectively analyzed. Results: The female to male ratio was 24/48, with a mean age of 62.7 ± 12.6 (minimum 27, maximum 88) years. The diagnosis of massive PE was established with echocardiography in all patients and was confirmed via pulmonary CT angiography in 45 patients (62.5%) who presented an appropriate clinical status for this imaging technique. The most common symptoms were dyspnea (90.3%), chest pain (83.3%), and syncope (40.2%). The S1Q3T3 electrocardiography pattern was noted in 82% of patients, who rapidly recovered after thrombolytic therapy. Cardiopulmonary arrest was seen in 25 patients (37.2%), and thrombolytic treatment was administered during cardiopulmonary resuscitation in 18% (n = 13) of patients. The survival rate was 30.7% (n = 4) in patients with cardiopulmonary arrest who received thrombolytic treatment in the emergency room. The complications of rt-PA treatment included minor hemorrhages in 6.4% (n = 5), major hemorrhages in 2.7% (n = 2), and allergic reactions in 1.3% (n = 1) of patients. None of the patients had deceased as a complication of thrombolytic treatment. The overall mortality rate was 26.2% (n = 19), and 12.5% (n = 9) of the patients have died in first 24 hours after thrombolysis. Conclusions: We concluded that the risk factors, ECG, and echocardiography are key indicators for the suspicion of massive PE in patients with hemodynamic shock. Based on our experience, early thrombolytic therapy is a life-saving intervention in patients with diagnosed and/or suspected massive PE.

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Life-Saving Systemic Thrombolysis in a Patient with Massive Pulmonary Embolism and a Recent Hemorrhagic Cerebrovascular Accident

Texas Heart Institute Journal ◽

10.14503/thij-12-3010 ◽

2014 ◽

Vol 41 (2) ◽

pp. 174-176 ◽

Cited By ~ 3

Author(s):

Wendy Bottinor ◽

Jeremy Turlington ◽

Syed Raza ◽

Charlotte S. Roberts ◽

Rajiv Malhotra ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Thrombolytic Therapy ◽

Cerebrovascular Accident ◽

Massive Pulmonary Embolism ◽

Thromboembolic Disease ◽

Venous Thromboembolic Disease ◽

Risk Of Death ◽

Coronary Syndrome ◽

Venous Thromboembolic

Massive pulmonary embolism is associated with mortality rates exceeding 50%. Current practice guidelines include the immediate administration of thrombolytic therapy in the absence of contraindications. However, thrombolysis for pulmonary embolism is said to be absolutely contraindicated in the presence of recent hemorrhagic stroke and other conditions. The current contraindications to thrombolytic therapy have been extrapolated from data on acute coronary syndrome and are not specific for venous thromboembolic disease. Some investigators have proposed that the current contraindications be viewed as relative, rather than absolute, in cases of high-risk pulmonary embolism. We present the case of a 60-year-old woman in whom massive pulmonary embolism led to cardiac arrest with pulseless electrical activity. Eight weeks earlier, she had sustained a hemorrhagic cerebrovascular accident—a classic absolute contraindication to thrombolytic therapy. Despite this practice guideline, we administered tissue plasminogen activator systemically in order to save the patient's life. This therapy did not evoke intracranial bleeding, and the patient was eventually discharged from the hospital. Until guidelines specific to venous thromboembolic disease are developed, we think that the current contraindications to thrombolysis should be considered on an individual basis in patients who are at high risk of death from massive pulmonary embolism.

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COVID-19 complicated by pulmonary embolism treated with catheter directed thrombectomy

VASA ◽

10.1024/0301-1526/a000880 ◽

2020 ◽

Vol 49 (4) ◽

pp. 333-337 ◽

Cited By ~ 3

Author(s):

Francisco Leonardo Galastri ◽

Leonardo Guedes Moreira Valle ◽

Breno Boueri Affonso ◽

Marcela Juliano Silva ◽

Rodrigo Gobbo Garcia ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Dynamic Process ◽

Therapeutic Option ◽

Massive Pulmonary Embolism ◽

Percutaneous Intervention ◽

Thromboembolic Events ◽

Emergency Center ◽

Catheter Directed Thrombolysis

Summary: COVID-19 is a recently identified illness that is associated with thromboembolic events. We report a case of pulmonary embolism in a patient with COVID-19, treated by catheter directed thrombectomy. A 57 year old patient presented to the emergency center with severe COVID-19 symptoms and developed massive pulmonary embolism. The patient was treated with catheter directed thrombolysis (CDT) and recovered completely. Coagulopathy associated with COVID-19 is present in all severe cases and is a dynamic process. We describe a case of massive/high risk pulmonary embolism, in a patient with COVID-19 receiving full anticoagulation, who was treated by percutaneous intervention. CDT can be an additional therapeutic option in patients with COVID-19 and pulmonary embolism that present with rapid clinical collapse.

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