Combined pulmonary thrombectomy and kidney embolization as bailout to thrombolysis: a case report

Systemic thrombolysis fails in around 8% of high-risk pulmonary embolism (PE) patients, and is associated with an increased risk of bleeding. Catheter-based aspirational thrombectomy (CAT) is emerging as a promising treatment option for PE, even when thrombolysis fails.

A 47-year-old woman, with short bowel syndrome and a history of previous pulmonary embolism presents with acute chest pain and haemodynamic instability. CT angiography showed central pulmonary embolism, and the patient was initially treated with acute thrombolysis. Despite this, the patient remained haemodynamically unstable and developed a life-threatening retroperitoneal bleed originating from the left kidney. A multidisciplinary team discussion was held among a PE cardiologist, interventional cardiologist, interventional radiologist, and an intensive care specialist. As the patient was considered too unstable for surgery, an emergency percutaneous embolization of the left kidney combined with CAT was planned. The renal arterial angiography showed diffuse ongoing capsular bleeding and was successfully embolized with particles (EmboSphere 300-500 um) and two microcoils in the main renal artery. Thereafter, bilateral thrombectomy was performed using the AlphaVac^® system, and several large thrombi were removed. The patient´s haemodynamic improved instantly, and she was discharged from the intensive care unit to the cardiac ward after 11 days.

In this case, an acute and life-threatening complication to systemic thrombolysis was successfully managed with acute combined percutaneous embolization and thrombus aspiration. This procedure required careful planning and cooperation involving multiple specialties, emphasizing the importance of multi-disciplinary team discussions in the management of complex PE patients.