Introduction: Patients diagnosed with a pulmonary embolus (PE) and are hemodynamically unstable are candidates for thrombolytic therapy. Our case report demonstrates a patient with postoperative, bilateral PEs that underwent CT angiography of the chest, transthoracic echocardiography (TTE), bilateral pulmonary arteriogram with pharmacologic and mechanical thrombolysis, and inferior vena cava (IVC) filter placement.

Methods: A 64 year old, critically ill, male underwent exploratory laparotomy and detorsion of a small bowel volvulus after undergoing a screening colonoscopy two days earlier. Nine days postoperatively, the patient became dyspneic and hypotensive. CT angiography of the chest revealed bilateral pulmonary emboli. The patient was started on an intravenous heparin drip and a TTE was performed revealing a dilated, hypokinetic right ventricle consistent with right ventricular dysfunction. Intravenous pressor support was required and the patient was taken to Interventional Radiology for a bilateral pulmonary arteriogram that revealed right middle lobe and left lower lobe emboli. Bilateral, catheter directed pharmacologic and mechanical thrombolysis with tissue plasminogen activator and Possis Angiojet® respectively was performed. A retrievable IVC filter was then successfully deployed within the infrarenal IVC. Pressor support was discontinued almost immediately within the radiology suite and post-procedure TTE revealed resolution of right ventricular dysfunction. The patient was maintained on therapeutic anticoagulation postoperatively and discharged from the hospital on day 43.

Conclusion: Our case report demonstrates successful catheter directed thrombolysis of bilateral pulmonary emboli within a hemodynamically unstable patient.