We present a case of acute massive pulmonary embolism in a 79 year old female patient who underwent mechanical thrombectomy with INARI FlowTriever device as thrombolysis was contraindicated due to a recent lower GI bleeding.

Patient is a 79 year old F who presented with worsening shortness of breath with diaphoresis for the past 24 hrs. She was recently discharged with community acquired pneumonia and lower GI bleeding. Patient didn’t received any blood transfusions and didnt have any workup for the GI bleed.

She has a medical history of HTN, Oxygen dependent COPD, GERD,had COVID pneumonia a few months ago. On physical examination she was afebrile, hypoxic saturating in mid 80s, tachycardia with HR 114- 130, BP 120-150/60-80 mm hg, RR 20-30. She was placed on NC 6L and eventually 2L saturating 98%. Labs showed BNP 2360, Troponin 0.7980, H/H 12.2/37.8, D-dimer 21.81,COVID negative. CXR showed cardiomegaly, scarring on left lung base, no pulmonary edema. Echocardiogram showed left ventricular ejection fraction 60-65% without regional wall abnormalities. Mildly dilated right ventricle with moderate to severe right ventricular dysfunction with presence of a RV strain and McConnell sign suggestive of PE. Moderate to severe pulmonary HTN, RVSP 46mm Hg. CTA chest showed extensive bilateral acute pulmonary emboli including saddle embolus in the main pulmonary artery and a left sided saddle embolus. Straightening of the interventricular septum is consistent with heart strain. Cardiology was consulted and patient was started on heparin drip and planned for percutaneous pulmonary thromboembolectomy with recent history of GI bleeding.

Patient had successful bilateral per cutaneous pulmonary thromboembolectomy using INARI FlowTriever device with complete aspiration across the right truncus anterior and near complete aspiration across the left lower lobe branches.

Intraoperatively patient noted to have a large pool of bright red blood per rectum and was hypotensive. She was started on vasopressor support and iv heparin was discontinued. She received 2 units of PRBCs and transferred to Cardiac unit. Patient developed right lower extremity DVT and recurrent episodes of GI bleeding for which she had IVC filter placement. GI workup revealed has multiple diverticulosis.

Various therapies for massive or submissive PE include surgical,embolectomy,systemic thrombolysis, and endovascular catheter directed lysis.The FlowTriever system is a mechanical thrombectomy designed specifically to extract thrombus from large vessels such as pulmonary arteries.Thrombolytic bleeding risks are eliminated in mechanical thrombectomy which make the FlowTriever System a promising treatment option for intermediate and higher risk PE. Our case report highlights the FlowTriever system approach for treatment of PE in a patient where anticoagulation and thrombolysis is contraindicated.