Low-Dose Catheter-Directed Thrombolysis for Massive Pulmonary Embolism: A Case Report Highlighting Dosing Considerations in Asian Patients

Clinical management of massive pulmonary embolism is challenging when active hemorrhage, a contraindication to thrombolytics, is concurrently present. We describe a successful attempt in using low-dose catheter-directed thrombolysis (CDT) in a high-risk patient with absolute contraindications to systemic thrombolysis. A 69-year-old Asian female with cardiac arrest was brought to a resource-limited rural hospital. The patient underwent 50 min of cardiopulmonary resuscitation (CPR) before regaining the pulse but remained in cardiogenic shock. Computerized tomography (CT) of the chest found massive PE. The patient was found with multiple fractures and subarachnoid hemorrhage. Catheter-directed embolectomy was performed without clinical improvement. A low-dose CDT with alteplase was attempted by giving 5 mg over 2 h with a repeated session 24 h later for a total of 10 mg. The patient started improving, was extubated on Day 9, and transferred out of the ICU on Day 15. Low-dose CDT in massive PE could be lifesaving despite the presence of absolute alteplase contraindications. Patients with contraindications, a high risk of bleeding, or of Asian race may benefit more from the low-dose alteplase regimen.