Mechanical Thrombectomy for Submassive Pulmonary Embolism in an Adult with Duodenal Adenocarcinoma and Brain Metastases

A 52-year-old African American man with small bowel adenocarcinoma metastatic to the brain and leptomeninges was found to have an acute pulmonary embolism while hospitalized for acute lower limb weakness, bowel, and urinary incontinence. He had an elevated troponin, echocardiographic findings concerning for right heart failure, and bilateral segmental and subsegmental pulmonary artery perfusion deficits with right pulmonary artery thrombus on CT angiography. Given the laboratory and radiographic findings with normotensive blood pressure, the patient was diagnosed with a submassive pulmonary embolism. After deliberation with interventional radiology and hematology, the patient underwent mechanical thrombectomy and was treated with therapeutic anticoagulation. Mechanical thrombectomy revealed substantial clot burden in the central pulmonary arteries and yielded a significant improvement in hypoxia and dyspnea. This case was an excellent exercise in therapeutic decision-making amidst a dynamic disease process that required integration of numerous clinical and diagnostic data points, including empiric anticoagulation with high clinical suspicion of acute pulmonary embolism, review of contraindications to anticoagulation and thrombolysis in metastatic malignancy, and the decision to pursue mechanical thrombectomy in the setting of contraindications to catheter-directed thrombolysis.