Large Saddle Pulmonary Embolism Safely Managed by Ultrasonic-supported Catheter-directed Thrombolytic Therapy.

A 40-year-old patient confirmed on computed tomography of the pulmonary arteries (CT/PAs) a large saddle pulmonary embolus in the main PA extending in both branches. He was managed by ultrasound-supported catheter-directed (EkoSonic, Boston Scientific) intrapulmonary thrombolytic therapy using a recombinant tissue plasminogen activator prolonged infusion over 16 h with a total dose of 50 mg divided in both PAs simultaneously with intravenous unfractionated heparin. He showed clinical improvement with improved arterial oxygen (PaO2) with reduced oxygen therapy with a nasal cannula. Follow-up right heart catheterization showed a significant reduction of PA pressure from 96/32 (mean 64) to 47/27 (mean 39) mmHg. Repeat pulmonary angiography showed significant improvement in PA branch opacification, suggesting increased flow and successful therapy. The patient received oral anticoagulants for months. He had followed with CT/PA and echocardiogram after 4 weeks, both were normalized. He resumed his regular physical activities, including exercises in the gymnasium.