AN UNCOMMON PRESENTATION OF THROMBUS-IN-TRANSIT AND MASSIVE ACUTE PULMONARY EMBOLISM

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Thrombus-in-transit is a rare presentation of venous thromboembolism, characterized by the presence of a floating clot traveling from the right heart into the pulmonary arterial vasculature. We present a case associated with massive pulmonary embolism (PE) in a patient with a contraindication to thrombolysis successfully treated with surgical thrombectomy. CASE PRESENTATION: A 50-year-old female with the diagnosis of Crohn’s disease presented with a one-week history of shortness of breath. On admission the patient was tachycardic, hypotensive and hypoxemic. The patient received intravenous fluids (IVF) and supplemental oxygen resulting in a transient stabilization of vital signs. Electrocardiogram showed ST depressions and T wave inversions in anteroseptal leads, Troponin- I was negative and D-dimer was elevated at 0.275 ug/mL. A chest computed tomography angiography revealed bilateral main pulmonary artery large filling defects, extending into segmental and sub-segmental arteries. Anticoagulation was started and the patient was admitted to the Medical Intensive Care Unit for close hemodynamic monitoring. A later transthoracic echocardiography showed a large hyperechoic, highly mobile mass in the right atrium, consistent with a thrombus-in-transit. The patient remained symptomatic and persistently hypotensive despite IVF. Thrombolysis was considered, but patient developed episodes of lower gastrointestinal bleeding due to Crohn’s disease flare. Cardiothoracic Surgery Service was consulted and patient underwent surgical bilateral pulmonary artery thrombectomy and removal of the right atrial thrombus. The patient was subsequently restarted on anticoagulation and discharged on day 19th post-surgery with excellent recovery. DISCUSSION: PE with thrombus-in-transit is a medical emergency that entails a high morbidity and mortality. Mortality rates can be as high as 50% in contrast to less than 10% in PE without a clot in transit. Early detection and intervention may decrease the risk of a catastrophic pulmonary embolism that can result in a poor outcome. Current therapeutic options include anticoagulation alone, medical thrombolysis and surgical thrombectomy. Although no randomized controlled trials have directly compared these treatment options, a systematic review article published in 2010 described a trend toward improved survival in surgical thrombectomy compared to thrombolysis and anticoagulation alone. On the other hand, a large study published in 2015, showed lower mortality rates with medical thrombolysis compared to surgical thrombectomy or anticoagulation alone (13.7%, 18.3% vs. 37.1%). CONCLUSIONS: PE with thrombus-in-transit is a life-threating condition that requires urgent intervention. Although no guideline recommendations have been established, surgical thrombectomy has shown high success rates and should be consider especially if contraindications to thrombolysis are present. Reference #1: Athappan G, Sengodan P, Chacko P, Gandhi S. Comparative efficacy of different modalities for treatment of heart thrombi in transit: a pooled analysis. Vasc Med. 2015;20(2):131-8. Reference #2: Myers PO, Bounameaux H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: systemic review of prognostic factors and treatment. Chest.2010;137(1):164-70. Reference #3: Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll.2003; 18:41(12):2245-51. DISCLOSURES: No relevant relationships by Renaud Gueret, source=Web Response No relevant relationships by VICTOR PRADO, source=Web Response No relevant relationships by MARTIN WATANABE, source=Web Response No relevant relationships by Luis Watanabe-Tejada, source=Web Response