Unpacking the 2026 Guidelines for Acute Pulmonary Embolism: What Interventional Radiologists and Cardiologists Need to Know-Slides: Case Example, Dr. Ranade

Slides: Case Example, Dr. Ranade

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This case describes a 77-year-old man with CLL and stage IV squamous cell carcinoma, recently treated with chemoradiation, who presented with acute substernal chest pain, severe shortness of breath, hypoxemia, and transient hypotension. EMS found his oxygen saturation at 84% on room air and systolic blood pressure in the 70s, improving after a 300 cc normal saline bolus and supplemental oxygen.<br /><br />CTA of the chest showed a large saddle pulmonary embolism with extensive clot burden, near-occlusion of the distal left main pulmonary artery, and extension into distal pulmonary arteries. Imaging also demonstrated right heart strain, including an RV/LV ratio of 1.6 and septal bowing. Bedside echocardiography confirmed a severely dilated right ventricle with reduced systolic function.<br /><br />Given his high-risk PE features, oncology-related prothrombotic state, and absence of absolute thrombolysis contraindications, the case was discussed with the oncology team and the PERT. Although bleeding risk was elevated due to age, malignancy, and recent procedures, systemic thrombolysis was initially avoided. The patient was deemed a candidate for catheter-directed thrombolysis (CDT), with mechanical thrombectomy as backup.<br /><br />Via right common femoral venous access, bilateral Unifuse catheters were placed. Pulmonary artery pressures were measured, and tPA was administered with a 10 mg bolus into the left main pulmonary artery followed by continuous infusion at 1 mg/hr per catheter on both sides. He was also maintained on heparin infusion and monitored in the MICU.<br /><br />Post-procedure, he experienced only a minor nosebleed treated with tranexamic acid. By postoperative day 1, he was off vasopressors and no longer required supplemental oxygen.

Keywords

saddle pulmonary embolism

catheter-directed thrombolysis

right heart strain

pulmonary embolism

thrombolysis

cancer-associated thrombosis

hypoxemia

heparin infusion

pulmonary artery catheter

transient hypotension