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High-Risk Pulmonary Embolism After Hemorrhagic Stroke: Management Considerations During Catheter-Directed Interventional Therapy

Published:April 06, 2022DOI:https://doi.org/10.1053/j.jvca.2022.04.001
      HIGH-RISK pulmonary embolism (PE) is characterized by right ventricular (RV) dysfunction, hemodynamic instability, and increased risk for early mortality that is estimated at between 25% and 65% of patients.
      • Konstantinides SV
      • Meyer G
      • Becattini C
      • et al.
      2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC).
      ,
      • Jaff MR
      • McMurtry MS
      • Archer SL
      • et al.
      Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association.
      Percutaneous catheter-directed intervention (CDI) has been recognized as a rapidly deployable, minimally invasive alternative option to surgical embolectomy when systemic thrombolytic therapy is contraindicated or ineffective.
      • Konstantinides SV
      • Meyer G
      • Becattini C
      • et al.
      2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC).
      • Jaff MR
      • McMurtry MS
      • Archer SL
      • et al.
      Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association.
      • Lewis AE
      • Gerstein NS
      • Venkataramani R
      • et al.
      Evolving management trends and outcomes in catheter management of acute pulmonary embolism [e-pub ahead of print].
      CDI techniques include fragmentation and rotational thrombectomy, suction thrombectomy, ultrasound-assisted thrombectomy, conventional catheter thrombolysis, and their combinations.
      • Engelberger RP
      • Kucher N.
      Catheter-based reperfusion treatment of pulmonary embolism.
      ,
      • Giri J
      • Sista AK
      • Weinberg I
      • et al.
      Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: A scientific statement from the American Heart Association.
      A hallmark of high-risk PE is acute severe RV dysfunction with hemodynamic instability, which can be aggravated by CDI and anesthetic procedures. There is a paucity of information about risks and complications associated with certain CDI techniques and their effect on anesthetic management. Furthermore, given the lack of high-level evidence, pre-existing high bleeding risk conditions can be a source of ambiguity in anesthetic management decisions. In this case report, the authors illustrate challenges to anesthetic care encountered during CDI for treatment of high-risk PE in the setting of a recent hemorrhagic stroke. The authors discuss anesthetic implications and provide recommendations for management in this setting based on the most recent evidence.

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