A 76-year-old woman with severe ischaemic heart disease being treated with aspirin, clopidogrel and metoprolol presents with severe abdominal and back pain, 6 hours after  being discharged home from a routine cardiac angiogram via the femoral route.

A large retroperitoneal  haematoma is diagnosed. After resuscitation, the bleeding is stopped by angiographic embolisation of a branch of the left internal iliac artery.
She  is  still  in  the  intensive care  unit  2  days  later  when  she  becomes suddenly dyspnoeic, hypoxaemic and hypotensive with a BP of 80 systolic. She stabilises and subsequent investigation reveals a moderate sized pulmonary embolism. 

Describe all the potential therapeutic strategies for her and describe in detail what your ongoing management would be in this case?

 

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College Answer

c)        She stabilises and subsequent investigation reveals a moderate sized pulmonary embolism.
Describe all the potential therapeutic strategies for her and describe in detail what your ongoing management would be in this case?

Strategies can be classified as medical or surgical. Medical therapy, the mainstay of treatment includes resuscitation with fluids and vasoactive support, anticoagulation, usually heparin with thrombolysis in cases usually of associated hypotension. Surgical therapy includes thrombectomy
+/- RVAD, and the use of IVC filters to help prevent recurrence.  The benefits and risks of each individual modality should be stated.

In the above scenario, she has stabilised, so systemic anticoagulation with heparin is indicated (the iliac artery branch tear has been embolised, so is unlikely to rebleed) but thrombolysis is possibly too risky and unnecessary after 2 recent angiograms, With the high likelihood of the embolism coming from the pelvic veins and other clot still present, the judicious employment of a filter may be wise.

Discussion

c)        She stabilises and subsequent investigation reveals a moderate sized pulmonary embolism.
Describe all the potential therapeutic strategies for her and describe in detail what your ongoing management would be in this case?

  • Management of the embolism
    • Anticoagulation
      • if permitted by the presence or absence of bleeding
    • Thrombolysis
      • unless there are contraindications (and it sounds like it is not indicated, given that she has stabilised)
    • Surgical embolectomy or interventional radiology clot retrieval are options to consider
  • Prevention of further emboli
    • anticoagulation (as above)
    • determination of source (lower limb doppler ultrasound)
    • inferior vena cava filter
  • Management of cardiovascular instability and hypoxia
    • high FiO2
    • minimise PEEP to decrease RV afterload
    • Optimal fluid loading to ensure RV preload is satisfactory
    • Pulmonary vasodilators and inotropes to improve forward flow through pulmonary circulation