Paradoxical Shock and Management of a Post-percutaneous Mechanical Thrombectomy Device in a Morbidly Obese Patient With a Submassive Pulmonary Embolism

A submassive pulmonary embolism (PE) is a type of PE where the pulmonary artery is partially obstructed. It is categorized as an intermediate risk when compared to massive PE, which presents as a complete obstruction of the pulmonary artery, therefore placing it in the high-risk category. In either case, if not promptly assessed and treated, it can prove to be fatal. We report the case of a morbidly obese middle-aged female who presented with a submassive PE. Based on the evaluation of the patient's pre-existing conditions, risk factors, clinical severity, imaging, and lab findings, it was concluded that percutaneous mechanical thrombectomy (PMT) was essential to promptly alleviate the clot burden. Following the procedure, it was observed that the patient became hemodynamically unstable, accompanied by hypoxemia and respiratory acidosis. With the assistance of pressors and later the placement of a right ventricular Impella device, the patient was successfully stabilized and, several days later, discharged from the hospital. This report explores the potential factors that may have contributed to the patient's hemodynamic instability and acute right ventricular failure after the PMT procedure. These factors can be attributed to pre-existing changes in the right ventricle (RV) as a result of morbid obesity, as well as possible associations with obstructive sleep apnea or obesity hypoventilation syndrome. Furthermore, it is important to highlight that patients exhibiting submassive PE can be considered suitable candidates for PMT, with careful consideration of the patient's medical history, clinical severity of symptoms, and diagnostic findings. It is worth noting that PMT intervention in this patient demonstrated a favorable outcome.