Intravascular ultrasound-guided pulmonary artery embolectomy for saddle pulmonary embolism.

A percutaneous catheter-directed treatment approach is preferred among patients with acute submassive pulmonary embolism (PE) and chronic kidney disease (CKD), who are at significant risk of bleeding with thrombolytics. Limiting contrast volume in these patients could reduce morbidity and mortality associated with contrast-induced acute kidney injury (CI-AKI). We present the case of a 61-year-old African American woman (BMI 46.9 kg/m ) with multiple comorbidities, including a PE 3 years prior (not currently on anticoagulation) and CKD (GFR 33 ml/min/1.73/m ), presented to the emergency department with 3 weeks of dyspnea on exertion which worsened 3-5 days preceding her presentation. On examination, she was hemodynamically stable, oxygen saturation was 88% on 5 l, in mild respiratory distress with bilateral lower extremity pitting edema. Troponin was 0.06 ng/ml (ref. <0.04), B-type natriuretic peptide was 932 pg/ml (ref. ≤78), arterial oxygen partial pressure was 56 (ref. 80-110) and hemoglobin was 10.1 g/dl (ref. 11.3-15.0). Computed tomography pulmonary angiography performed with IV contrast showed a saddle embolus with evidence of right heart strain (RV/LV ratio: 2.05). A transthoracic echocardiogram showed a dilated RV and mean pulmonary artery pressure was 53 mmHg on right heart catheterization. She underwent a successful catheter-directed pulmonary embolectomy with the aid of an intravascular ultrasound (IVUS) along with fluoroscopy. To prevent CI-AKI, intravenous contrast was not used for the procedure. To the best of our knowledge, this is the first reported case of an "IVUS-only" approach in a patient with acute submassive PE and CKD.