Thrombolysis in pulmonary embolism: are we under-using it?

Successful thrombolysis of normotensive pulmonary embolism with life-threatening hypoxia in a young man with Klinefelter syndrome

Klinefelter syndrome (KS) affects males born with an additional X chromosome giving the genotype 47XXY classically. This syndrome has primary features of infertility and hypogonadism along with other features including a genetically hypercoagulable state. When associated with other risk factors, KS further increases the risk of venous thromboembolism and could result in life-threatening pulmonary embolism (PE). There should be a lower threshold in suspecting PE as a cause of acute respiratory failure in this patient group and thrombolysis should be considered early in normotensive PE with severe hypoxia for best patient outcomes. Furthermore, clinicians should be cautious in managing testosterone therapy in patients with KS and additional thromboembolic risk factors.

Massive pulmonary embolism following recovery from COVID-19 infection: inflammation, thrombosis and the role of extended thromboprophylaxis

COVID-19 is the infectious disease caused by a recently discovered SARS-CoV-2. Following an initial outbreak in December 2019 in Wuhan, China, the virus has spread globally culminating in the WHO declaring a pandemic on 11 March 2020. We present the case of a patient with an initial presentation of COVID-19 pneumonitis requiring mechanical ventilation for nearly 2 weeks and total admission time of 3 weeks. She was given prophylactic dose anticoagulation according to hospital protocol during this time. Following a week at home, she was readmitted with acute massive pulmonary embolism with severe respiratory and cardiac failure, representing the first such case in the literature.

Treatment of Pulmonary Embolism Using Ultrasound-Accelerated Thrombolysis Directly Into Pulmonary Arteries

Traditional therapy for pulmonary embolism includes systemic anticoagulation, systemic thrombolysis, catheter-directed thrombolysis / suction catheter thrombectomy, and surgical thromboembolectomy. Currently, the standard treatment for submassive and massive pulmonary embolism involves the use of systemic anticoagulation. However, unlike systemic anticoagulation there is no standard treatment algorithm for the use of thrombolytics to aggressively treat pulmonary embolism and its sequelae. This case report discusses the successful use of thrombolytics using the EKOS EkoSonic Ultrasound-Accelerated Thrombolysis System in the treatment of bilateral submassive pulmonary emboli along with a saddle pulmonary embolus. The EKOS ultrasound-accelerated thrombolysis procedure resulted in rapid substantial clinical improvement, resolution of bilateral pulmonary emboli along with resolution of the saddle pulmonary embolus, restoration of pulmonary blood flow with resolution of pulmonary hypertension, and normalization of pulmonary embolism-related cardiac dysfunction. This novel application of ultrasound-accelerated thrombolytic infusion directly into the pulmonary arteries for pulmonary embolism provides a potential new treatment option and a valuable addition to the treatment algorithm for the management of both submassive and massive pulmonary embolism.

Tenecteplase in the treatment of acute pulmonary thrombo-embolism

This is a retrospective study documenting the use of tenecteplase in 41 cases of suspected or confirmed pulmonary embolism receiving in-hospital tenecteplase as per weight-adjusted dosing in addition to standard heparin and oral anticoagulant therapy. The presenting symptoms of dyspnoea, chest pain, hemoptysis and syncope were found in 40 (97.56%), 19 (46.34%), 6 (14.63%) and 9 (21.95%) patients, respectively. There was one case of mortality who was a 26 yrs old female of postpartum pulmonary thrombo-embolism with severe hypotension, cyanosis, bilateral crepitations in lungs and pulmonary hypertension. In the 40 survived patients, there was alleviation of dyspnoea and hemoptysis in all patients. Significant reduction in tachycardia (P < 0.0001) and increase in the oxygen saturation (SaO₂) (P < 0.0001) were seen at discharge as compared to at the time of presentation. Eighteen patients had hypotension which recovered in all patients till the time of discharge (P < 0.0001). There was a significant reduction in right ventricular systolic pressure in all 18 patients who underwent 2-D echocardiography both before and after the tenecteplase therapy. Resolution of pulmonary embolism on CT pulmonary angiography was documented in only two patients. No bleeding events or any other adverse events were reported during this study. The present study suggests favourable efficacy of tenecteplase in patients with suspected or confirmed acute pulmonary embolism. Although no major adverse events were noted, a large prospective study on the use of tenecteplase in pulmonary embolism is suggested.

A comparison of the ADC and T2 mapping in an assessment of blood-clot lysability

The structural characteristics of blood clots are associated with their susceptibility to thrombolysis. As their morphology can be characterized by MRI, several attempts have been made to link the lysability of blood clots with their MRI properties; however, so far no study has associated a clot's lysability with the diffusion properties of the water in the clot. The apparent diffusion coefficient (ADC) is highly sensitive to changes in serum mobility and may be used to distinguish between the non-retracted and the fully retracted regions of the blood clot. Therefore, the ADC may be a suitable, or even a better, marker for an assessment of the clot's retraction and consequently for its lysability than the relaxation time T(2). The purpose of this study was to evaluate whether it is possible to predict the outcome of clot thrombolysis by ADC mapping prior to treatment. After two hours of thrombolysis using a recombinant tissue plasminogen activator in plasma, whole-blood clots were efficiently dissolved in regions with ADC >or= 0.8 x 10(-9) m(2)/s or T(2) >or= 130 ms, whereas dissolution was poor and prolonged in regions with ADC < 0.8 x 10(-9) m(2)/s or T(2) < 130 ms. An analysis based on a comparison between the initial and final ADC and T(2) maps after two hours of thrombolysis showed that the ADC can more accurately detect the different grades of clot retraction than T(2) and predict the regions of a clot that are resistant to thrombolysis. Therefore, the ADC could be used as an efficient prognostic marker for the outcome of thrombolysis. However, in vivo studies are needed to test this idea.