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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 40-42

Aggressive emergency interventional management in a case of intraoperative massive pulmonary embolism


Department of CTVS (Medicine), Jagjivan Ram Western Railway Hospital, Mumbai, Maharashtra, India

Date of Submission21-Dec-2019
Date of Decision02-Mar-2020
Date of Acceptance05-Mar-2020
Date of Web Publication20-Apr-2020

Correspondence Address:
Dr. Saurabh Ajit Deshpande
Department of CVTS, Jagjivan Ram Railway Hospital, M M Marg, RBI Staff Colony, Mumbai Central, Mumbai - 400 008, Maharashtra State
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_53_19

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  Abstract 


Acute pulmonary embolism (PE) is commonly associated with trauma-related orthopedic procedures (63% or even higher). Massive PE in this setting requires meticulous treatment decisions to reduce bleeding risk. We hereby present such a case where we successfully used a combination of fibrinolysis and catheter-directed fragmentation and multidisciplinary approach for intraoperative massive PE.

Keywords: Bleeding, catheter-directed fragmentation, fibrinolysis, multidisciplinary, pulmonary embolism


How to cite this article:
Roul SK, Kumar S, Reddy MV, Deshpande SA. Aggressive emergency interventional management in a case of intraoperative massive pulmonary embolism. J Indian coll cardiol 2020;10:40-2

How to cite this URL:
Roul SK, Kumar S, Reddy MV, Deshpande SA. Aggressive emergency interventional management in a case of intraoperative massive pulmonary embolism. J Indian coll cardiol [serial online] 2020 [cited 2020 Aug 14];10:40-2. Available from: http://www.joicc.org/text.asp?2020/10/1/40/282977




  Introduction Top


Pulmonary embolism (PE) during the perioperative period is fairly common, especially in the traumatic orthopedic injuries (63% clinical and even higher subclinical.[1]) Massive PE has a very high mortality rate, which exceeds 50%.[2] Hence, prompt diagnosis and management are of utmost importance in such cases.[3] The management strategy in the perioperative period for massive PE should be based on the risk and benefit of each procedure[4] (i.e., fibrinolysis, mechanical thrombolysis/thrombus fragmentation, etc.,). We present a case of intraoperative massive PE in a traumatic femoral shaft fracture fixation procedure which was managed by a multidisciplinary approach.


  Case Report Top


A 52-year-old female, without any prior atherosclerotic risk factors, presented to the orthopedic department with a history of trauma to the leg during a road traffic accident around 10 days back. She was referred from an outside hospital for corrective surgery. She was evaluated and counseled for spinal and general anesthesia (if required). She was in the American Society of Anesthesiologists Grade II with normal blood investigations and electrocardiogram (ECG). After appropriate fasting period and written informed consent, she was taken up for open reduction and internal fixation with nailing/plating of fracture shaft of the femur.

A few minutes into the procedure, there was a sudden fall in oxygen saturation from 98% to 40% on room air, with a lowering of consciousness. The patient developed hypotension. Cardiopulmonary resuscitation was then started. Injection adrenaline was given intravenously. The airway secured with 7-mm endotracheal tube. Surgery was stopped with an open leg wound. Oxygen saturation was at 30% even with 100% FiO2(with positive end-expiratory pressure of 6 cm H2O and ETCO2 of 26 mm Hg). On auscultation, she was found to have preserved air entry without any adventitial sounds. Hence, acute massive PE was suspected. Arterial blood gas evaluation showed mixed acidosis (pH of 7.1). ECG [Figure 1]a showed sinus tachycardia at the rate of 150 bpm, rightward axis (120°) with limb leads showing right ventricular strain pattern and S1Q3T3 sign. Intraoperative transthoracic echocardiogram [Figure 1]b revealed dilated right atrium and right ventricle (RV), dilated main pulmonary artery with filling defect, D-shaped interventricular septum in both systole and diastole with preserved left ventricular function. RV systolic dysfunction was noted [tricuspid annular plane systolic excursion (TAPSE) = 9mm]. Pulmonary artery systolic pressure (PASP) was 30 mm Hg.
Figure 1: (a) Electrocardiogram (b) echocardiogram

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The surgery was then stopped with an open leg wound which was packed to prevent blood loss. The supportive management with fluid resuscitation was started. The patient was given bolus intravenous heparin (5000 IU) and started on fibrinolysis with alteplase (10 mg bolus followed by infusion of 90 mg over 2 h). After hemodynamic stabilization, she was shifted to the catheterization laboratory for pulmonary angiography.

On invasive evaluation, the main pulmonary artery was dilated with no filling defect. Left pulmonary artery and left-sided lobular arteries showed good peripheral filling [Figure 2]. The right-sided pulmonary artery was occluded at the division, and the upper lobar branch was not visible with poor peripheral filling [Figure 3]a. The right pulmonary artery was wired, and the catheter was tracked over it. Mechanical thrombus fragmentation was performed. After mechanical fragmentation also there was significant residual thrombus in the right pulmonary artery [Figure 3]b. The patient was kept on anticoagulation with heparin. The patient developed bleeding postfibrinolysis and required three packed red cell transfusions due to a significant fall in hemoglobin.
Figure 2: Left pulmonary angiogram

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Figure 3: Right pulmonary angiogram (a) before and (b) after mechanical thrombus fragmentation

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Bilateral lower limb doppler done on day 4 postprocedure showed thrombotic occlusion of the left tibial-peroneal trunk and posterior tibial vein. Multiple detector computed tomography (CT) done on day 4 postprocedure showed a partial filling defect in bilateral pulmonary arteries. Inferior vena cava (IVC) filter [Figure 4]a was put electively on day 8 postprocedure, and the patient was taken up for the treatment of fracture shaft of the femur. The procedure was completed under combinedspinalepiduralanesthesia without any complications. IVC filter was kept for a whole year and CT chest was done. It was found to be free of thrombus. The IVC filter was then removed [Figure 4]b. Echocardiogram repeated at the time of discharge revealed recovered RV systolic function with PASP of 25 mmHg.
Figuren 4: Inferior vena cava filter (a) deployment (b) retrieval

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She was kept on anticoagulation till 6 months after IVC filter removal. She is completely asymptomatic off oral anticoagulation after follow-up of around 28 months.


  Discussion Top


Surgery increases the risk of PE almost five times, making it to be a major life-threatening complication.[5] Orthopedic surgical procedures have an incidence of PE ranging from 0.7%–30% in different case series.[6] Fat embolism is a common cause of PE during orthopedic surgery, especially during the treatment of long bone fractures.[7] The mortality in an untreated massive PE can be as high as 70%.[8] Hence, prompt initiation of treatment is of paramount importance.

Treatment of PE in a perioperative setting requires a multidisciplinary approach with a team consisting of a cardiologist, anesthetist, and operating surgeon, etc., The risk of bleeding has to be weighed against the benefit of the treatment strategy to be undertaken.[9] Various treatment modalities such as systemic fibrinolysis, catheter-directed fibrinolysis, catheter-directed thrombectomy, or surgical embolectomy are available. Massive PE with hemodynamic stability and right ventricular dysfunction may be treated with low mortality by surgical embolectomy.[10] As the patient was hemodynamically stable and bleeding could have been controlled while still on the operating table, the option of anticoagulation with fibrinolysis was attempted.

A pulmonary angiogram is the gold standard for the diagnosis of PE, but an early diagnosis can be made with ECG and bedside echocardiogram (as was done in our case) before deciding on the management. Mohan et al.[11] studied the use of catheter-directed fragmentation (CDF) in the treatment of acute high-risk PE to find that rapid reperfusion of pulmonary arteries with mechanical fragmentation followed by intrapulmonary thrombolysis results in excellent immediate and intermediate-term outcomes. We have also used a combination of fibrinolysis with CDF for the treatment with a good outcome.

There was a 4% incidence of major bleeding requiring transfusion in the study done in 2014.[11] Similarly, in our case, there was increased bleeding, which required blood transfusion.

In conclusion, the treatment of perioperative PE is an emergency and requires a team approach. A combination of fibrinolysis with CDF is feasible and safe in such a situation, but it may entail an increased risk of bleeding.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Toker S, Hak DJ, Morgan SJ. Deep vein thrombosis prophylaxis in trauma patients. Thrombosis 2011;2011: 505373.  Back to cited text no. 1
    
2.
Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circ 2006;113:577-82.  Back to cited text no. 2
    
3.
Wood KE. Major pulmonary embolism: Review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002;121:877-905.  Back to cited text no. 3
    
4.
Yamamoto T. Management of patients with high-risk pulmonary embolism: A narrative review. J Intensive Care 2018;6:16.  Back to cited text no. 4
    
5.
Segaran S, Arish B, Mohan A, Jayaraman V, Ramchandran A. A case of successful management of perioperative pulmonary embolism. J Curr Res Sci Med 2018;4:2:112-5.  Back to cited text no. 5
    
6.
Arcelus JI, Kudrna JC, Caprini JA. Venous thromboembolism following major orthopedic surgery: What is the risk after discharge? Orthopedics 2006;29:506-16.  Back to cited text no. 6
    
7.
Gavrankapetanović I. Fat embolism in orthopedic surgery. In: Papović A, editor. Fat Embolism in Orthopedic Surgery. Ch. 7. Rijeka: IntechOpen; 2017. Available from: https://doi.org/10.5772/67710. [Last accessed on 2019 Nov 05].  Back to cited text no. 7
    
8.
Hsieh PC, Wang SS, Ko WJ, Han YY, Chu SH. Successful resuscitation of acute massive pulmonary embolism with extracorporeal membrane oxygenation and open embolectomy. Ann Thorac Surg 2001;72:266-7.  Back to cited text no. 8
    
9.
Dudaryk R, Benitez Lopez J, Louro J. Diagnosis and thrombolytic management of massive intraoperative pulmonary embolism guided by point of care transthoracic echocardiography. Case Rep Anesthesiol 2018;2018: 8709026.  Back to cited text no. 9
    
10.
Carvalho EM, Macedo FI, Panos AL, Ricci M, Salerno TA. Pulmonary embolectomy: Recommendation for early surgical intervention. J Card Surg 2010;25:261-6.  Back to cited text no. 10
    
11.
Mohan B, Aslam N, Kumar Mehra A, Takkar Chhabra S, Wander P, Tandon R, et al. Impact of catheter fragmentation followed by local intrapulmonary thrombolysis in acute high risk pulmonary embolism as primary therapy. Indian Heart J 2014;66:294-301.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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