1. Percutanous thrombolysis of massive pulmonary embolism in an unstable post-op patient with recent epidural catheter and a prolonged cardiac arrest.

2. We have no relevant financial relationships
Radha Mehta, MD
Steven Rudick, MD
Timothy Smith, MD
Satya Shreenivas, MD
We have no relevant financial relationships

3. Learning objectives
Know how to recognize massive pulmonary embolism (PE) in post-op patients.
Understand management options of massive PE in patients with strong contraindications to systemic thrombolysis
Tips/Tricks for reducing complications with percutaneous thrombolysis of massive PE.

4. Clinical Presentation
WM is a 48 y.o. male with appendiceal adenocarcinoma who is 5 days status-post right hemicolectomy and local (peritoneal) administration of chemotherapy.
He had an epidural catheter in place for pain control post-operatively.

5. Clinical Presentation
On the morning of post-op day 5, his epidural catheter was removed. Within 90 minutes of that removal he experienced acute onset of hypoxia (oxygen saturation on room air: 70%) and tachycardia (heart rate: 140s-150s) followed by PEA arrest.
He underwent ACLS for 23 minutes until ROSC was obtained. He required the support of multiple vasopressors. Central vein access using the femoral vein was attempted during the code with several vessel punctures but unsuccessful line placement.

6. Figure 1: Immediate bedside echocardiogram, though limited by artifact, revealing a grossly dilated RV with evidence of reduced RV systolic function

7. Figure 2: Emergent pulmonary angiogram revealed acute pulmonary embolism with large clot burden in the distal left main pulmonary artery and loss of the left lower lobar segment. There is stranding of clot in the right pulmonary artery with loss of right middle lobe perfusion.

8. Clinical Presentation
Despite several classic contraindications to systemic lytic therapy, his unstable clinical condition prompted referral to our interventional pulmonary response system. After extensive discussion of risks/benefits, the decision was made to proceed with bilateral EKOS catheter placement for localized lytic infusion with a reduced tPA infusion rate of 0.5 mg  per hour per catheter for 24 hours, to minimize the risk of cord hematoma or life threatening head, chest or abdominal bleed.

9. Figure 3: EKOS catheter placement

10. Clinical Presentation
He tolerated the procedure well and was transferred to the CVICU in stable condition. The entire procedure was completed in less than one hour with improvement in vasopressor requirements and hypoxemia within 4 hours.
He was extubated about 16 hours after EKOS placement
tPA infusion stopped after 24 hours of therapy and EKOS catheters removed. Introducer sheaths removed at 24 and 48 hours without complication. PTT goals adjusted appropriately
He was discharged home 5 days after EKOS treatment on indefinite enoxaparin therapy and no neurologic compromise.

11. Follow Up Studies
Figure 4: Post-EKOS echocardiogram revealing significantly improved RV:LV ratio and improvement in RV systolic function

12. Take Home Messages
It is important to have high suspicion of PE in post-operative patients with hypoxemia, tachycardia, and PEA arrest.
Local thrombolysis with EKOS catheter resulted in an excellent outcome in the post-operative patient with a very tenuous course with contraindications to systemic thrombolysis.

13. Tips/Tricks to decrease complications
Procedure was done quickly to ensure best chance for target organ recovery (from cardiac arrest to cath lab to patient being in the cath lab less than 30 minutes elapsed).
Femoral access was obtained with ultrasound, micro-puncture technique and fluoroscopic guidance to ensure low risk for vascular complications.
Reduced thrombolytic drip rate was used to decrease the risk for cord hematoma and head, chest or abdominal bleed.