Recurrent massive pulmonary embolism following catheter directed thrombolysis in a 21-year-old with COVID-19: a case report

Hirschbaum, Julian H; Bradley, C P; Kingsford, P.; Mehra, Anilkumar; Kwan, Wilson

doi:10.1093/ehjcr/ytab140

Cited by 3 publications

(2 citation statements)

References 16 publications

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“…Acute COVID-19 infections have been associated with hypercoagulability and thromboembolic complications ( 56 ). There is a report of an adolescent successfully utilizing dual CDT for segmental and subsegmental PE in the setting of acute COVID-19 as well as a 21-year-old with recurrent PE undergoing successful CDT for bilateral PE ( 12 , 57 ). Yet, in adolescents and children, MIS-C has been shown to have a higher TE incidence than acute COVID-19 infections ( 58 ).…”

Section: Thrombolysis In Childrenmentioning

confidence: 99%

Thrombolysis in Children: A Case Report and Review of the Literature

et al. 2022

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Thromboembolism (TE), including venous thromboembolism (VTE), arterial TE, arterial ischemic stroke (AIS), and myocardial infarction (MI), is considered a relatively rare complication in the pediatric population. Yet, the incidence is rising, especially in hospitalized children. The vast majority of pediatric TE occurs in the setting of at least one identifiable risk factor. Most recently, acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have demonstrated an increased risk for TE development. The mainstay for the management pediatric TE has been anticoagulation. Thrombolytic therapy is employed more frequently in adult patients with ample data supporting its use. The data for thrombolysis in pediatric patients is more limited, but the utilization of this therapy is becoming more commonplace in tertiary care pediatric hospitals. Understanding the data on thrombolysis use in pediatric TE and the involved risks is critical before initiating one of these therapies. In this paper, we present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to MIS-C requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children.

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Section: Thrombolysis In Childrenmentioning

confidence: 99%

Thrombolysis in Children: A Case Report and Review of the Literature

et al. 2022

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“…Cases of cerebral infarcts as well as venous and cardiac thrombosis have been reported in children requiring extracorporeal membrane oxygenation (ECMO) for COVID-19 or MIS-C [31 ▪ ,37 ▪ ,38–40]. Adult studies have reported an increased risk of venous, arterial, and circuit thrombosis in patients requiring ECMO for COVID-19 [41,42].…”

Section: Thrombotic Events In Children With Coronavirus Disease 2019 ...mentioning

confidence: 99%

Thrombotic events in critically ill children with coronavirus disease 2019 or multisystem inflammatory syndrome in children

Dain

Raffini

Whitworth

2022

Current Opinion in Pediatrics

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Purpose of review To provide an update regarding what is known about thrombotic events and thromboprophylaxis in critically ill children with SARS-CoV-2 infection. Recent findings Pediatric patients with SARS-CoV-2 generally have mild illness; however, intensive care is required in about 20–30% of hospitalized children with COVID-19 and an even higher proportion in those with MIS-C. Increased rates of thrombosis have been observed in adults hospitalized with COVID-19, and clinical trials have attempted to optimize thromboprophylaxis. There is significant variability in the estimated incidence of thrombosis in pediatric patients (0–27%) because of variation in patient populations and study design. Multiple studies demonstrate an increased rate of thrombosis compared with baseline in hospitalized pediatric patients. Few studies have evaluated risk factors for thrombosis, but critical illness, older age, and other known thrombosis risk factors appear to increase the risk. Thromboprophylaxis strategies are inconsistent, with little evidence of efficacy but few reports of major bleeding. Summary Critically ill children with SARS-CoV-2-related illnesses are at increased risk of thrombosis. Thromboprophylaxis should be considered in select patients with COVID-19 or MIS-C, though the optimal strategy is not yet known. More data is required to guide practice to prevent thrombosis in this population.

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Heparin

2021

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A-21-year-old man exhibited lack of efficacy during treatment with heparin for pulmonary embolism [dosage not stated]. The man presented to the emergency department with 3 days of fever, shortness of breath, cough, pleuritic chest pain, and 1 day of lightheadedness with near syncope and worsened dyspnoea. At the time of the presentation, he was febrile, normotensive, tachycardic and hypoxic. The severe acute respiratory syndrome coronavirus 2 nasopharyngeal qualitative polymerase chain reaction (PCR) was positive. Electrocardiogram (ECG) demonstrated evidence of right heart strain, a pattern associated with acute pulmonary embolism. His ultrasound scan showed right ventricular free wall hypokinesis with preserved apical contractility consistent with pulmonary embolism. Initial D-Dimer, troponin-T and pro-BNP-NT levels were elevated. A computed tomography pulmonary angiogram (CTPA) demonstrated pulmonary emboli. He was admitted to the intensive care unit (ICU) on high flow nasal cannula and started receiving treatment with IV heparin [unfractionated heparin] infusion. He was persistently hypotensive and hypoxic. He was presumptively diagnosed with massive pulmonary embolism. He was urgently underwent catheter-directed thrombolysis (CDT). The treatment with IV heparin infusion was continued. Following CDT, he improved clinically and was transferred to the general medicine floor on hospital day 3. On hospital day 4, he was initially normotensive, and developed hypotension and acute respiratory failure, which required a non-re-breather mask. Subsequently, he was intubated and developed cardiac arrest regaining spontaneous circulation after one electrical shock and two rounds of cardiopulmonary resuscitation. Vasopressor support was initiated with phenylephrine, epinephrine, norepinephrine and vasopressin. Recurrence of pulmonary embolism was suspected, and his pulmonary angiogram demonstrated bilateral pulmonary emboli with interval worsening of clot burden. Repeat CDT of the bilateral pulmonary arteries was performed with continuous systemic IV heparin infusion. Over the next 48h, ventilation parameters improved, and vasopressors were discontinued. Repeat pulmonary angiography demonstrated significant improvement in the right central pulmonary embolism. Venous duplex ultrasound was then performed demonstrating non-occlusive thrombus of the right femoral vein and popliteal vein. An inferior vena cava filter was placed.The man's anticoagulation regimen was transitioned from heparin to enoxaparin sodium [enoxaparin] due to concern for failure of anticoagulation. He was successfully weaned from extracorporeal membrane oxygenation (ECMO) on hospital day 10 and extubated on hospital day 31. He received treatment for septic shock treated with broad spectrum antibiotics and developed a right thigh haematoma and compartment syndrome required surgical debridement on hospital day 40. Postoperatively, he was transitioned to rivaroxaban. On hospital day 52, he was discharged to an acute rehabilitation facility. He returned home ...

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Recurrent massive pulmonary embolism following catheter directed thrombolysis in a 21-year-old with COVID-19: a case report

Cited by 3 publications

References 16 publications

Thrombolysis in Children: A Case Report and Review of the Literature

Thrombolysis in Children: A Case Report and Review of the Literature

Thrombotic events in critically ill children with coronavirus disease 2019 or multisystem inflammatory syndrome in children

Heparin

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