Stepwise Escalation of Reperfusion Therapy in Massive Pulmonary Embolism With Right Ventricular Failure

High-risk (massive) pulmonary embolism (PE) is associated with early mortality due to right ventricular (RV) failure and obstructive shock. Current guidelines recommend anticoagulation and systemic thrombolysis for hemodynamically unstable PE, with escalation when thrombolysis is contraindicated or ineffective at restoring perfusion.

A 54-year-old man with past prior deep venous thrombosis presented abroad with sudden-onset dyspnea, hypotension, and severe hypoxemia requiring emergent intubation. Computed tomography pulmonary angiography showed extensive bilateral pulmonary emboli with severe RV dysfunction. The patient received systemic alteplase followed by catheter directed thrombolysis, but persistent thrombotic burden and RV dysfunction prompted international transfer for further management. Repeat imaging revealed a residual massive saddle PE, and emergent large-bore mechanical thrombectomy restored hemodynamic stability. Recovery was complicated by encephalopathy, autonomic instability, and critical illness myopathy requiring tracheostomy and inpatient rehabilitation.

This case highlights that incomplete response to thrombolysis in massive PE may warrant escalation to advanced reperfusion strategies. Postreperfusion, neurologic and functional complications can be major barriers to recovery despite achieving hemodynamic stability.

Persistent RV dysfunction or clot burden despite thrombolysis should prompt consideration of advanced reperfusion strategies and proactive intensive care unit recovery planning.