Submassive Pulmonary Thromboembolism in a Patient with Thrombocytopenia: Therapeutic Challenge

Abstract

Venous thromboembolic disease is an important cause of mortality worldwide. A widely recognized risk factor is active neoplasia, mainly hematological tumors, in which associated thrombocytopenia can be a frequent complication. We present the case of a patient with submassive pulmonary thromboembolism associated with severe thrombocytopenia with signs of right heart failure and a requirement for systemic thrombolysis and anticoagulation, however with absolute contraindication for them. The case establishes a therapeutic challenge for the treating group, leading us to carry out an extensive search of the literature and propose a management algorithm in this complex situation.

Acute pulmonary artery thromboembolism in presence of large mobile right atrial thrombus and severe thrombocytopenia

“…Considering the presence of severe thrombocytopenia, hemodynamic instability, and large mobile intracardiac thrombus, high-risk surgery was performed, after taking the consent for the same [ 2 ]. She underwent successful removal of the intracardiac thrombus and pulmonary artery thrombus until subsegmental branches (Fig.…”

“…Many reports are available in the literature for successful thrombolysis in cancer patients having thrombocytopenia. Surgical embolectomy is often considered as first-line therapy for patients with thrombus in the right heart or across a patent foramen ovale (clot-in-transit) [ 2 , 5 ]. However, the optimal management of PE-associated right heart thrombi and thrombocytopenia remains unclear owing to the low number of cases.…”

“…Report from Tovar et al suggests thrombolysis remains the first line of management in this group of patients. However, authors advised surgical/open embolectomy in patients with hemodynamic instability as was the scenario in the present case [ 2 ]. This is probably a rare case with a successful outcome with surgical management.…”

EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer

“…126,195,196 Accordingly, data for thrombolysis in patients with TP and cancer are scarce. 197 Based on the high risk of bleeding in case of systemic thrombolysis, this therapy in patients with TP and cancer should be avoided or considered only on a case-by-case basis in high-risk patients with massive PE (with persistent arterial hypotension or shock) and only in centers with appropriate expertise. It must be emphasized that full-dose intravenous thrombolysis can be associated with life-threatening bleeding complications, particularly intracranial hemorrhage, even in the absence of TP.…”

“…Based on current guidelines, since cancer patients have a higher incidence of VTE but also a higher incidence of bleeding, malignancy is a relative contraindication to systemic (intravenous) thrombolysis in VTE 126,195,196 . Accordingly, data for thrombolysis in patients with TP and cancer are scarce 197 . Based on the high risk of bleeding in case of systemic thrombolysis, this therapy in patients with TP and cancer should be avoided or considered only on a case‐by‐case basis in high‐risk patients with massive PE (with persistent arterial hypotension or shock) and only in centers with appropriate expertise.…”