Delayed mechanical thrombectomy after systemic thrombolysis in massive unilateral pulmonary thromboembolism

Pulmonary thromboembolism (PTE) remains the third leading cause of cardiovascular death, after a heart attack and stroke. Haemodynamically unstable PTE (previously called high-risk or massive) is one of the dreaded conditions commonly found in people working in high-altitude areas. Due to the individual variations in clot characteristics and the haemodynamics, these patients offer unique therapeutic challenges by delay in access to tertiary care, being recalcitrant to the systemic thrombolysis as well as complete recanalisation by endovascular thrombectomy. We present a rare case of haemodynamically unstable right pulmonary trunk occlusion with delayed presentation and sustained right ventricular strain despite systemic thrombolysis, managed successfully by catheter-directed thrombectomy. Despite the partial recanalisation of only the right inferior pulmonary artery branches and persistent superior branch occlusion, there was an immediate clinical benefit and no recurrence of symptoms with maintenance therapy of newer oral anticoagulants.