(1186) The Confounder Within: A Case of CTED Confounding the Management of Acute Pulmonary Embolism

Introduction: Pulmonary embolism (PE) is a common pulmonary vascular disease with a heterogeneous presentation and high mortality. Despite advances in management of high risk and intermediate-high risk pulmonary embolism (IHRPE), the associated mortality and morbidity remains high. Chronic thromboembolic disease (CTED) is an under-recognized comorbidity in acute PE management.

Description: A 72 year old male with acute myeloid leukemia, recurrent metastatic prostate cancer, atrial fibrillation, and chronic kidney disease admitted to our center after repeat emergency department evaluations for exertional dyspnea was found to have IHRPE by current criteria on computed tomography angiogram. The patient was transferred after discussion with the PE response team (PERT). Initial vitals were BP 98/73, HR 115 in atrial fibrillation, RR 27 and SpO2 91% on 6L, with lactate 8.7 mmol/L, troponin I 50.7 pg/ml, and BNP 17,029 pg/ml. His BOVA, PESI and NEWS score were 7, 162, and 12 respectively. After further PERT discussion he went for large bore mechanical thrombectomy by interventional radiology. Intra-procedurally, under conscious sedation, there was difficulty with clot evacuation. The minimal clot obtained appeared to be fibrinous, consistent with a chronic clot. He developed rapidly progressing hypotension, hemodynamic deterioration, and went into cardiac arrest. He was pronounced dead on the procedure table without further support per his goals of care. On review postmortem, the patient had a transthoracic echocardiogram from 15 years prior in another healthcare system that showed probable pulmonary hypertension as evidenced by PASP of 30mmHg. On detailed evaluation of the pulmonary vasculature there were irregular segmental filling defects, eccentric thrombi, webs and distal pruning most consistent with CTED.

Discussion: Chronic thromboembolic pulmonary hypertension (CTEPH) and CTED are underlying pathologies to consider in the diagnosis and treatment of acute PE, which portend adverse outcomes. The acute on chronic spectrum of this presentation confounds current risk stratification and results in uncertainty surrounding the evolving treatment paradigm for acute PE. Mortality in acute PE treated with mechanical thrombectomy may be underreported and warrants further investigation.