John Hunter Hospital, Newcastle, New South Wales
Background: The use of intravenous thrombolysis has been demonstrated as efficacious and warranted in cases of haemodynamically unstable pulmonary embolism but a relative contraindication to use has traditionally been recent surgery within 1 month. Mortality with massive pulmonary embolism has been documented as high as 50%, however, the use of thrombolysis carries an estimated 20% risk of major haemorrhage.
Case report: A 49 year old gentleman presented with symptomatic palpitations in the context of known paroxysmal atrial fibrillation and was found to be in decompensated rapid atrial fibrillation with a BP of 70/40mmHg. He received intravenous digoxin with some improvement in his heart rate but despite 4 litres of intravenous fluids and continuous metaraminol infusion in the coronary care unit was persistently hypotensive. Ventilation Perfusion scan performed the day of admission revealed multiple bilateral pulmonary emboli. This gentleman received a cadaveric renal transplant two weeks prior with an uneventful discharge at day 9 with a serum creatinine of 123 µmol/L. A history of laboratory and clinical thrombophilia preceded the renal transplant with known positive lupus anticoagulant and issues with clotted lines on haemodialysis. This gentleman had a background of Alports’ syndrome with a history of previous dual-cadaveric renal transplantation in 2010 which ultimately failed and he resumed haemodialysis in 2016. Given his clinical instability, a multidisciplinary decision was made to administer thrombolysis which led to immediate clinical improvement. There were no adverse effects on his graft despite initial reservations using thrombolysis in this patient during this early post-operative period.
Conclusions: Renal transplantation may not preclude the use of thrombolysis in the early post-operative period in a deteriorating patient with life-threatening pulmonary thromboembolism.