Systemic Thrombolysis for Intraoperative, High Risk Pulmonary Embolism, Clinical Case

Abstract

A 68-year-old woman with intercondylar fracture of the femur suffers massive (high risk) pulmonary embolism (PE) during surgery and is suc-cessfully treated with systemic thrombolysis. After limb exsanguinations with Esmarch bandage, the patient presents with sudden oxygen desaturation (99% to 80%) with subsequent dyspnea and hypotension. She is intubated and requires continuous adrenalin perfusion while the surgery is finished and until she can be transferred to the reanimation ward. We decide to perform transthoracic echocardiogram (her general condition impedes transfer to tomography) which confirms right ventricular overload and pulmonary hypertension. These findings justify systemic thrombolysis, which is performed with good results. Surgery, and in particular orthopedic surgery, increase the risk of PE. When considering high risk PE, guidelines recommend primary reperfusion strategy through systemic thrombolysis (which can be contraindicated in surgery patients) or catheter-assisted thrombus removal (less widely available). Lately, surgical pulmonary embolectomy is being discussed as a treatment option for patients with contraindication to thrombolysis, but this practice is still uncommon.