|Year : 2020 | Volume
| Issue : 3 | Page : 154-157
Acute high-risk pulmonary embolism following spine surgery successfully treated by pharmaco-mechanical intervention
Barun Kumar1, Ashwin Kodliwadmath1, Amar Upadhyay2, Anupam Singh3, N Nanda4
1 Department of Cardiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Paediatrics, Doon Medical College, Dehradun, Uttarakhand, India
3 Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 Department of Endocrinology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||17-Sep-2020|
|Date of Decision||18-Sep-2020|
|Date of Acceptance||02-Oct-2020|
|Date of Web Publication||26-Nov-2020|
Dr. Ashwin Kodliwadmath
Department of Cardiology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Acute high-risk pulmonary embolism (PE) is defined as PE with either cardiac arrest, obstructive shock, or persistent hypotension at presentation. The incidence of venous thromboembolism (VTE) is lower following spine surgery compared to joint arthroplasty surgeries. The use of anticoagulants after spine surgery for the prevention of VTE is associated with a definite risk of epidural hematoma resulting in neurologic sequelae. Here, we report a case of a 57-year-old female who presented with cardio-respiratory arrest following spine surgery due to acute high-risk PE. In view of recent spine surgery and traumatic cardiopulmonary resuscitation, which are considered as contraindications for systemic thrombolysis and unavailability of cardiac surgery unit, the patient was treated with pharmaco-mechanical intervention resulting in successful recovery with no development of epidural hematoma or neurologic sequelae. Prophylactic anticoagulation for the prevention of VTE and the risk of epidural hematoma should be balanced after a case of spine surgery.
Keywords: Catheter-directed treatment, pulmonary embolism, spine surgery, thrombolysis
|How to cite this article:|
Kumar B, Kodliwadmath A, Upadhyay A, Singh A, Nanda N. Acute high-risk pulmonary embolism following spine surgery successfully treated by pharmaco-mechanical intervention. Heart India 2020;8:154-7
|How to cite this URL:|
Kumar B, Kodliwadmath A, Upadhyay A, Singh A, Nanda N. Acute high-risk pulmonary embolism following spine surgery successfully treated by pharmaco-mechanical intervention. Heart India [serial online] 2020 [cited 2021 Jan 21];8:154-7. Available from: https://www.heartindia.net/text.asp?2020/8/3/154/301597
| Introduction|| |
Venous thromboembolism (VTE), clinically presenting as deep vein thrombosis (DVT) or pulmonary embolism (PE), is globally the third-most frequent acute cardiovascular syndrome behind myocardial infarction and stroke. DVT and PE are potential complications following major orthopedic surgical procedures, predominantly total hip arthroplasty and total knee arthroplasty. In the absence of prophylaxis, DVTs occur in as much as 84% of elective hip and knee arthroplasty cases with up to 36% being proximal lesions. The incidence of PE has been reported to range from 9% to 30% with fatal events occurring in 0.1%–0.7% of the cases. The incidence of VTE has been known to be lower following spine surgery when compared to joint replacement surgeries. The incidence of DVT has been reported to range from 0% to 15.5%, while the incidence of PE has been reported to range from 0% to 13.1%. History of recent traumatic cardiopulmonary resuscitation (CPR) in a case of acute high-risk PE eliminates the most common treatment option of systemic thrombolysis from the options. Risk of development of epidural hematoma with the use of systemic thrombolysis in a patient with recent spine surgery cannot be overstated. Here, we present a case of a 57-year-old female who presented to us with acute high-risk PE following spine surgery with cardiac arrest and was successfully treated with the pharmaco-mechanical approach.
| Case Report|| |
We report the case of a 57-year-old female of north Indian ethnicity, who was operated for lumbar disc prolapse by the neurosurgery team. She was advised elastic stockings for the prevention of VTE postsurgery. On the postoperative day 1, she was clinically doing well during morning rounds at 8 am, and advised mobilization by the treating surgeon. After around 30 min, the patient hemodynamically collapsed while trying to walk and CPR was started according to advanced cardiac life support protocol. Forty-five minutes of high-quality CPR was instituted, which resulted in the return of spontaneous circulation (ROSC). She was intubated and connected to ventilator and managed by the critical care team. Our cardiology team was informed about the case 4 h after the cardiac arrest for consultation. Hemodynamic collapse followed by cardiac arrest in the immediate postoperative period made us think in lines of either massive PE or perioperative myocardial infarction. Examination revealed a sick female with a pulse rate of 130 bpm, feeble to palpation and blood pressure (BP) of 60/30 mmHg on the support of 3 inotropes at maximum dose. Arterial blood gases revealed hypoxia, type I respiratory failure with severe metabolic acidosis of pH 6.9. Twelve lead surface electrocardiogram (ECG) done after ROSC showed sinus tachycardia, right bundle branch block (RBBB) and S1Q3T3 pattern [Figure 1]a. Bedside chest X-ray (CXR) showed homogeneous opacity on the left hemithorax involving mid and lower zones suggestive of “Hampton's hump” [Figure 1]b. Screening bedside echocardiography done showed normal left ventricular (LV) function, right atrial/right ventricular (RA/RV) enlargement with severe RV dysfunction with McConnel sign, moderate tricuspid regurgitation (TR) with peak TR gradient of 55 mmHg and pulmonary acceleration time of 52 s suggestive of the 60/60 sign. In view of the patient on mechanical ventilator, computerized tomography pulmonary angiography (CTPA) was not performed. It was diagnosed as a case of acute high-risk PE and low-molecular-weight heparin was started. In view of prolonged traumatic CPR and a history of recent spine surgery, systemic thrombolysis was a contraindication. There was no cardiothoracic vascular surgery expertise available for surgical embolectomy. Hence, catheter-directed intervention (CDI) was the only left treatment option. After written informed consent, multipurpose (MP) A1 catheter was passed from the right femoral vein → right atrium (RA)→right ventricle (RV)→pulmonary artery (PA), and pulmonary angiography was performed. Baseline pulmonary artery pressure (PAP) was 92/64 mmHg. Pulmonary angiography of the left pulmonary artery (LPA) showed a large thrombus burden in the LPA with obstruction [Figure 2]a. Mechanical fragmentation was done with the help of J-tipped Terumo wire resulting in some improvement in flow [Figure 2]b and [Figure 2]c. Catheter-directed thrombolysis was done with 9 mg tenecteplase resulting in further improvement of flow [Figure 2]d. Nonspecific injection of the right pulmonary artery showed large thrombus in the right main pulmonary artery [Figure 3]a. Mechanical fragmentation was done with the J-tipped Terumo wire resulting in some flow [Figure 3]b and [Figure 3]c. Catheter-directed thrombolysis was done with 9 mg tenecteplase, resulting in further improvement in flow [Figure 3]d. PAP measured after the completion of the procedure was 64/36 mm of Hg. At the end of the procedure, the BP was 90/60 mmHg. In 12 h, the BP improved to 120/76 mmHg, and we started to taper the inotropes. She was continued on enoxaparin 60 mg subcutaneous twice daily. By the 2nd and 3rd days, she developed hematuria, local site haematoma and ecchymoses and the hemoglobin (Hb) dropped to 70 g/L from 120 g/L (normal 120–160 g/L for females) and she received three units of red blood cell transfusion resulting in improvement in the Hb, while enoxaparin was continued. Over the next 4 days, her Glasgow coma scale improved but developed fever with a white blood cell (WBC) count of 26 × 109/L (normal 4–11 × 109/L). Blood culture revealed Streptococcus pnuemoniae sensitive to tigecycline which was started. She was off inotropic support by day 8 and extubated after a successful weaning trial. Over the next 3 days, the WBC count started to decrease and tablet warfarin was started at a dose of 3 mg once daily and enoxaparin stopped once International Normalised Ratio was therapeutic. She was mobilized on the postopeartive day 16 and doing well while no development of epidural hematoma was evident. Lower limb Doppler detected no deep-vein thrombi, ECG showed incomplete RBBB and T inversion in lead III [Figure 4]a and CXR showed normal lung fields [Figure 4]b. Echocardiography showed normal LV, RV function with a resolution of RA/RV enlargement. She was discharged on day 21 with warfarin 3mg once daily with no residual cardiopulmonary or neuro-orthopedic deficit. CTPA done after 1 month showed no evidence of PE. She is still in follow-up with us for the past 1 year and doing clinically well.
|Figure 1: (a) Twelve lead surface electrocardiogram showing sinus tachycardia, right bundle branch block and S1Q3T3 pattern. (b) Bedside chest X-ray anteroposterior view showing homogeneous opacity on the left hemithorax involving mid and lower zones|
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|Figure 2: (a) Fluoroscopic image showing pulmonary angiography of the left pulmonary artery with multipurpose A1 catheter, with catheter course from the right femoral vein, inferior vena cava, right atrium, right ventricle, main pulmonary artery, left pulmonary artery, showing large thrombus burden in the left pulmonary artery with obstruction indicated by arrowheads. (b) Fluoroscopic image showing mechanical fragmentation of left pulmonary artery thrombus using J-tipped Terumo wire. (c) Fluoroscopic image showing in some improvement in flow in the left pulmonary artery after mechanical fragmentation with the persistence of some thrombus as indicated by the arrowheads. (d) Fluoroscopic image showing further improvement of flow in the left pulmonary artery after local instillation of 9 mg tenecteplase|
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|Figure 3: (a) Fluoroscopic image showing nonspecific injection of the right pulmonary artery using multipurpose A1 catheter, with catheter course from the right femoral vein, inferior vena cava, right atrium, right ventricle, main pulmonary artery, right pulmonary artery, revealing large thrombus in the right main pulmonary artery as indicated by the arrowheads. (b) Fluoroscopic image showing mechanical fragmentation of right pulmonary artery thrombus with the J-tipped Terumo wire. (c) Fluoroscopic image showing in some improvement in flow in the right pulmonary artery after mechanical fragmentation, with the persistence of some thrombus as indicated by the arrowhead. (d) Fluoroscopic image showing further improvement of flow in the right pulmonary artery after local instillation of 9mg tenecteplase|
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|Figure 4: (a) Twelve lead surface electrocardiogram showing incomplete right bundle branch block and T inversion in the lead III. (b) Chest X-ray posteroanterior view showing normal lung fields and normal cardiac silhouette|
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| Discussion|| |
Acute high-risk PE is defined as PE with either cardiac arrest, obstructive shock or persistent hypotension at presentation. Although CTPA is the investigation of choice, it may not be feasible to get it done in hemodynamically unstable patients and echocardiographic findings of 60/60 sign and the McConnel sign which are specific markers of PE aid in the diagnosis. Treatment can include systemic thrombolysis, percutaneous CDI or surgical embolectomy. Catheter-directed thrombolysis is more efficacious at lower doses and has a lower bleeding risk and can be accompanied by adjuvant mechanical fragmentation or rheolytic thrombectomy. With respect to thrombus fragmentation, the fact that the cross-sectional area of the distal arterioles is more than four times that of the central circulation and that the volume of the peripheral circulatory bed is about twice that of the pulmonary arteries suggests that the redistribution of large central clots into smaller clots in the peripheral pulmonary arteries may acutely improve cardiopulmonary hemodynamics, with significant increases in the total pulmonary blood flow and RV function. Fragmentation can also be used as a complement to thrombolytic therapy because fragmentation of a large clot exposes fresh surfaces on which endogenous urokinase and infused thrombolytic drugs can work to further break down the resulting emboli. Although CDI involves catheterization of the pulmonary arteries, it is much less invasive than open surgical embolectomy. When patients are poor candidates for systemic thrombolysis and surgical embolectomy, CDI may be the only viable treatment option and should be pursued if available. Although the risk of VTE after spine surgery is less than that of joint replacement surgeries, the risk of developing a life-threatening PE cannot be ignored. Accepted methods for VTE prophylaxis after spine surgery are the use of elastic stockings, intermittent pneumatic compression, or a combination of the two or use of anticoagulants but with an accepted risk of 0.7% of developing epidural hematoma. Although the risk of VTE after spine surgery is low, a high index of suspicion for PE should be kept for any hemodynamic deterioration postoperatively and early diagnosis and treatment can decrease morbidity and mortality.
| Conclusion|| |
Risk of VTE is lower following spine surgery than joint replacement surgery but can be catastrophic. CDI is a safer treatment option in cases of acute high-risk PE following spine surgery as it has lower chances of epidural hematoma and resulting neurologic sequelae. Prophylactic anticoagulation for the prevention of VTE and the risk of epidural hematoma should be balanced after a case of spine surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Barun Kumar and Ashwin Kodliwadmath: conception. Anupam Singh and Barun Kumar: case report. Ashwin Kodliwadmath and Amar Upadhyay: investigations. Amar Upadhyay and Nanda N: discussion. Anupam Singh and Nanda N: critical appraisal.
| References|| |
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al
. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2019;54:1-61.
Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA Jr., et al
. Prevention of venous thromboembolism. Chest 2001;119:132-75S.
Rokito SE, Schwartz MC, Neuwirth MG. Deep vein thrombosis after major reconstructive spinal surgery. Spine 1996;21:853-8.
Oda T, Fuji T, Kato Y, Fujita S, Kanemitsu N. Deep venous thrombosis after posterior spinal surgery. Spine 2000;25:2962-7.
Rosner MK, Kuklo TR, Tawk R, Moquin R, Ondra SL. Prophylactic placement of an inferior vena cava filter in high-risk patients undergoing spinal reconstruction. Neurosurg Focus 2004;17:E6.
Kelly P, Carroll N, Grant C, Barrett C, Kocka V. Successful treatment of massive pulmonary embolism with prolonged catheter-directed thrombolysis. Heart Vessels 2006;21:124-6.
Tajima H, Murata S, Kumazaki T, Nakazawa K, Abe Y, Komada Y, et al
. Hybrid treatment of acute massive pulmonary thromboembolism: Mechanical fragmentation with a modified rotating pigtail catheter, local fibrinolytic therapy, and clot aspiration followed by systemic fibrinolytic therapy. Am J Roentgenol 2004;183:589-95.
Kuo WT, Van den Bosch MA, Hoffman LV, Louie JD, Kothary N, Sze DY. Catheter-directed embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis. Chest2008;134:250-4.
Schizas C, Neumayer F, Kosmopoulas V. Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis. Eur Spine J 2008;17:970-4.
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