High-Risk Pulmonary Embolism After Hemorrhagic Stroke: Management Considerations During Catheter-Directed Interventional Therapy

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HIGH-RISK pulmonary embolism (PE) is characterized by right ventricular (RV) dysfunction, hemodynamic instability, and increased risk for early mortality that is estimated at between 25% and 65% of patients. 1 Konstantinides SV Meyer G Becattini C et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019; 541901647 PubMed Google Scholar ,2 Jaff MR McMurtry MS Archer SL et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association. Circulation. 2016; 123: 1788-1830 Crossref Scopus (1577) Google Scholar Percutaneous catheter-directed intervention (CDI) has been recognized as a rapidly deployable, minimally invasive alternative option to surgical embolectomy when systemic thrombolytic therapy is contraindicated or ineffective. 1 Konstantinides SV Meyer G Becattini C et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019; 541901647 PubMed Google Scholar , 2 Jaff MR McMurtry MS Archer SL et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association. Circulation. 2016; 123: 1788-1830 Crossref Scopus (1577) Google Scholar , 3 Lewis AE Gerstein NS Venkataramani R et al. Evolving management trends and outcomes in catheter management of acute pulmonary embolism [e-pub ahead of print]. J Cardiothorac Vasc Anesth. 2021; (Accessed May 28, 2022)https://doi.org/10.1053/j.jvca.2021.09.050 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar CDI techniques include fragmentation and rotational thrombectomy, suction thrombectomy, ultrasound-assisted thrombectomy, conventional catheter thrombolysis, and their combinations. 4 Engelberger RP Kucher N. Catheter-based reperfusion treatment of pulmonary embolism. Circulation. 2011; 124: 2139-2144 Crossref PubMed Scopus (96) Google Scholar ,5 Giri J Sista AK Weinberg I et al. Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: A scientific statement from the American Heart Association. Circulation. 2019; 140: e774-e801 Crossref PubMed Scopus (139) Google Scholar A hallmark of high-risk PE is acute severe RV dysfunction with hemodynamic instability, which can be aggravated by CDI and anesthetic procedures. There is a paucity of information about risks and complications associated with certain CDI techniques and their effect on anesthetic management. Furthermore, given the lack of high-level evidence, pre-existing high bleeding risk conditions can be a source of ambiguity in anesthetic management decisions. In this case report, the authors illustrate challenges to anesthetic care encountered during CDI for treatment of high-risk PE in the setting of a recent hemorrhagic stroke. The authors discuss anesthetic implications and provide recommendations for management in this setting based on the most recent evidence.