SESSION TITLE: Pulmonary Vascular Disease Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Acute Pulmonary Embolism (PE) is usually stratified into high risk, intermediate risk and low risk. Current recommendations on the management of acute PE are based on hemodynamic stability, and systemic thrombolysis is contraindicated in absence of shock. Hemodynamically stable patients are usually treated with systemic anticoagulation and followed closely for any signs of decompensation such as decrease in systolic BP, increase in heart rate, worsening gas exchange, signs of inadequate perfusion, worsening right ventricular function, or increasing cardiac biomarkers. In cases which develop any of the above signs, and there is no risk of bleeding, thrombolysis is advised.(1) More recently, in patients with sub-massive PE, aspiration thrombectomy has been shown to be effective.(2) We present such a case of successful delayed aspiration thrombectomy after failed therapeutic anticoagulation and worsening clinical indicators.CASE PRESENTATION: A 58-year-old lady with a family history of venous thrombo-embolism. presented to the ED with a history of right calf pain, palpitations, chest tightness and dyspnea on exertion for about 2 weeks. She was post-menopausal, on hormone replacement therapy. Upon admission, she had elevated levels of D-dimer (5225 ng/mL) and NT-proBNP (647 pg/mL). CTA PE protocol showed saddle PE, high clot burden in the left proximal segmental branches with near total occlusion. Transthoracic echocardiogram revealed a mildly enlarged right ventricle, and trace mitral and tricuspid regurgitation. McConnell's sign was also present. Given her hemodynamic stability and no hypoxia, she was placed on a heparin drip for therapeutic anticoagulation. Next day, she developed new worsening of dyspnea and pleuritic chest pain. After a multidisciplinary team meeting, a decision was made to pursue aspiration thrombectomy which led to successful retrieval of her saddle embolus and significant improvement in her symptoms. She was discharged on Apixaban with a plan for close follow up.DISCUSSION: High clot burden (70% perfusion deficit) is a known predictor of poor prognosis. Our case exemplifies a successful delayed aspiration thrombectomy due to initial hemodynamic stability, despite extensive clot burden. Clinical decision in this setting was difficult as to when to escalate management from therapeutic anticoagulation to thrombolysis. Given our patient was on therapeutic anticoagulation, systemic thrombolytics would add to adverse event risk if used.CONCLUSIONS: There are no clear guidelines defining the time period to wait or follow up with imaging before expecting improvement in clinical condition. It is unclear, from current evidence, whether there is a benefit of early thrombectomy in these patients. Further studies are needed to define the optimal timing and management, especially in this subset of patients, who do not initially present with hemodynamic instability.Reference #1: Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing G-J, et al. Executive Summary: Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. CHEST [Internet]. 2021 Dec 1 [cited 2022 Apr 2];160(6):2247–59. Available from: https://journal.chestnet.org/article/S0012-3692(21)01507-5/abstractReference #2: Sista AK, Horowitz JM, Tapson VF, Rosenberg M, Elder MD, Schiro BJ, et al. Indigo Aspiration System for Treatment of Pulmonary Embolism: Results of the EXTRACT-PE Trial. JACC Cardiovasc Interv. 2021 Feb 8;14(3):319–29.DISCLOSURES: No relevant relationships by LOVELEEN BHOGALNo relevant relationships by Prashant JagtapNo relevant relationships by Akshay KohliNo relevant relationships by Robert KroppNo relevant relationships by Abhishek Kalidas KulkarniNo relevant relationships by Kevin SchraderNo relevant relationships by Muhammad Adil Sheikh SESSION TITLE: Pulmonary Vascular Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Acute Pulmonary Embolism (PE) is usually stratified into high risk, intermediate risk and low risk. Current recommendations on the management of acute PE are based on hemodynamic stability, and systemic thrombolysis is contraindicated in absence of shock. Hemodynamically stable patients are usually treated with systemic anticoagulation and followed closely for any signs of decompensation such as decrease in systolic BP, increase in heart rate, worsening gas exchange, signs of inadequate perfusion, worsening right ventricular function, or increasing cardiac biomarkers. In cases which develop any of the above signs, and there is no risk of bleeding, thrombolysis is advised.(1) More recently, in patients with sub-massive PE, aspiration thrombectomy has been shown to be effective.(2) We present such a case of successful delayed aspiration thrombectomy after failed therapeutic anticoagulation and worsening clinical indicators. CASE PRESENTATION: A 58-year-old lady with a family history of venous thrombo-embolism. presented to the ED with a history of right calf pain, palpitations, chest tightness and dyspnea on exertion for about 2 weeks. She was post-menopausal, on hormone replacement therapy. Upon admission, she had elevated levels of D-dimer (5225 ng/mL) and NT-proBNP (647 pg/mL). CTA PE protocol showed saddle PE, high clot burden in the left proximal segmental branches with near total occlusion. Transthoracic echocardiogram revealed a mildly enlarged right ventricle, and trace mitral and tricuspid regurgitation. McConnell's sign was also present. Given her hemodynamic stability and no hypoxia, she was placed on a heparin drip for therapeutic anticoagulation. Next day, she developed new worsening of dyspnea and pleuritic chest pain. After a multidisciplinary team meeting, a decision was made to pursue aspiration thrombectomy which led to successful retrieval of her saddle embolus and significant improvement in her symptoms. She was discharged on Apixaban with a plan for close follow up. DISCUSSION: High clot burden (70% perfusion deficit) is a known predictor of poor prognosis. Our case exemplifies a successful delayed aspiration thrombectomy due to initial hemodynamic stability, despite extensive clot burden. Clinical decision in this setting was difficult as to when to escalate management from therapeutic anticoagulation to thrombolysis. Given our patient was on therapeutic anticoagulation, systemic thrombolytics would add to adverse event risk if used. CONCLUSIONS: There are no clear guidelines defining the time period to wait or follow up with imaging before expecting improvement in clinical condition. It is unclear, from current evidence, whether there is a benefit of early thrombectomy in these patients. Further studies are needed to define the optimal timing and management, especially in this subset of patients, who do not initially present with hemodynamic instability. Reference #1: Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing G-J, et al. Executive Summary: Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. CHEST [Internet]. 2021 Dec 1 [cited 2022 Apr 2];160(6):2247–59. Available from: https://journal.chestnet.org/article/S0012-3692(21)01507-5/abstract Reference #2: Sista AK, Horowitz JM, Tapson VF, Rosenberg M, Elder MD, Schiro BJ, et al. Indigo Aspiration System for Treatment of Pulmonary Embolism: Results of the EXTRACT-PE Trial. JACC Cardiovasc Interv. 2021 Feb 8;14(3):319–29. DISCLOSURES: No relevant relationships by LOVELEEN BHOGAL No relevant relationships by Prashant Jagtap No relevant relationships by Akshay Kohli No relevant relationships by Robert Kropp No relevant relationships by Abhishek Kalidas Kulkarni No relevant relationships by Kevin Schrader No relevant relationships by Muhammad Adil Sheikh