Catheter Directed tPA for treatment of acute PE in setting of Sickle Cell Disease and Severe Right Ventricular Failure
Austin Tutor MD, Justin Price MD, Arthur Davis MD, Jose Tafur MD
Introduction Hemoglobin SC disease is the second most common subtype of sickle cell disease (SCD). Venous thromboembolism is a well-known complication of SCD and can present as pulmonary emboli (PE) with an associated mortality estimated as high as 30%. The mainstay of treatment for PE is anticoagulation. Acute treatment can also involve thrombolytics or embolectomy for patients with sub-massive or massive PEs. Case Presentation A 37-year-old male presented with abdominal pain and shortness of breath. Laboratory evaluation on admission was significant for elevated liver enzymes and bilirubinuria. A CT angiogram was unable to be performed secondary to acute renal failure. A VQ scan showed a high probability for PE. Transthoracic echo was notable for severe right ventricular (RV) failure with RVEDD 6.28cm and TAPSE 1.1cm, flattening of the interventricular septum, and severe pulmonary artery systolic pressure (PASP) elevation to 82mmHg. Lower extremity venous duplex ultrasound confirmed multiple, bilateral deep venous thromboses. Due to his RV failure and multisystem organ failure despite treatment with continue IV heparin, we proceeded with a catheter directed tPA continuous infusion for 12 hours at 1mg/hr in addition to dobutamine. After 5 days of treatment, PASP decreased to 34mmhg and his liver and renal function returned to normal. He was able to be weaned off dobutamine, transitioned from intravenous heparin to apixaban, and discharged home. Discussion Sickling of red blood cells results in small vessel occlusion and vasoconstriction leading to local vascular ischemia. PE in patients with SCD is often underdiagnosed as patient often have confounding factors including dyspnea secondary to anemia and acute chest syndrome. Conversely, sickle cell patients are also at a higher risk of hemorrhagic conversion. Catheter directed tPA was chosen as rescue therapy for our hemodynamically stable intermediate-high risk sub-massive PE patient (Class IIa, European Society of Cardiology). Conclusion: Our case demonstrates the sequelae of multiorgan failure in a sickle cell anemia (HbSC) patient with an acute PE with a high risk of hemorrhagic conversion. The patient made complete recovery with catheter direct tPA after failing medical treatment with IV heparin.
Made with FlippingBook Digital Publishing Software