Ultrasound-Facilitated Catheter-Directed Thrombolysis via Dual Right Upper Extremity Venous Access Into the Basilic Vein in a Case of Submassive Pulmonary Embolism

Traditionally, massive, life-threatening pulmonary embolism (PE) has been treated with systemic thrombolytic therapy while submassive and smaller acute PEs have been treated with systemic anticoagulation therapy. Given that thrombolytic therapy is associated with the risk of life-threatening complications including intracranial hemorrhage, it has not been routinely used or recommended for submassive PEs. In 2017, the Food and Drug administration (FDA) approved ultrasound-facilitated catheter-directed thrombolysis (USCDT) for acute massive and sub-massive pulmonary embolism. USCDT has primarily been performed using jugular or femoral venous access. There have been isolated reports of USCDT performed through upper extremity venous access. We present a case of USCDT in a submassive PE patient with dual right upper extremity venous access where both sheaths were advanced into the basilic vein (due to anatomic variation). Based on recent clinical trial data suggesting that shorted duration USCDT is as effective as longer duration, tissue plasminogen activator (tPA) was infused in this case for 6 hours. This strategy for intervention can enhance patient comfort with USCDT therapy and can be particularly helpful in patients at high risk for access site complications and those unable to lie supine for the long duration of infusion therapy.