DOI: 10.12890/2026_006153
Sequential systemic thrombolysis for clot-in-transit after thrombolytic failure in massive pulmonary embolism
Authors
maccvans@gmail.com
Keywords
Clot-in-transit, pulmonary embolism, thrombolytic failure, sequential thrombolysisAbstract
Introduction: A clot-in-transit (CIT) is a mobile thrombus within the right heart associated with acute pulmonary embolism (PE) and high mortality. Although systemic thrombolysis remains the standard treatment for massive or high-risk PE, management of thrombolytic failure and associated CIT remains challenging, particularly when surgical embolectomy and catheter-directed thrombectomy are unavailable. Sequential systemic thrombolysis represents a practical therapeutic option in these high-risk scenarios.
Case description: A 54-year-old woman with hypertension presented with progressive dyspnoea and pleuritic chest pain. Computed tomography pulmonary angiography confirmed massive bilateral PE, and she was treated with intravenous tenecteplase. Despite initial hemodynamic improvement, hypoxemia persisted, and echocardiography revealed a large CIT within the right atrium. In the absence of surgical or catheter-directed options, she received repeat systemic thrombolysis with alteplase, achieving complete thrombus resolution and rapid clinical recovery without bleeding complications. Further evaluation revealed large uterine fibroids compressing the iliac veins as the likely source of extensive deep vein thrombosis.
Discussion: This case demonstrates the potential role of sequential systemic thrombolysis in managing thrombolytic failure and CIT when advanced interventions are unavailable. Switching to alteplase after unsuccessful thrombolysis with tenecteplase may enhance thrombus dissolution due to pharmacological differences in fibrin affinity and duration of fibrinolytic activity. Early reassessment following thrombolysis is critical to detect persistent thrombus and guide timely intervention.
Conclusion: Sequential systemic thrombolysis can serve as a safe, effective, and practical rescue strategy for clot-in-transit complicating massive PE, particularly in low-resource settings where surgical or catheter-based interventions are not available.
References
- Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J 2020;41:543–603. doi: 10.1093/eurheartj/ehz405
- Zhang Z, Xi L, Zhang S, Zhang Y, Fan G, Tao X. Tenecteplase in pulmonary embolism patients: a meta-analysis and systematic review. Front Med (Lausanne) 2022;9:860565. doi: 10.3389/fmed.2022.860565
- Meneveau N, Seronde MF, Blonde MC, Legalery P, Didier-Petit K, Briand F, et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006;129:1043–1050. doi: 10.1378/chest.129.4.1043
- Patel AN, Amrutiya RJ, Manvar BN. A proposed approach for the management of clot-in-transit. Cureus 2022;14:e28481. doi: 10.7759/cureus.28481
- Bigdelu L, Ebrahimi N, Maadarani O. Recurrent high-risk pulmonary thromboembolism treated with repeated thrombolytic therapy: a case report and review of the literature. Eur J Case Rep Intern Med 2023;10:004042. doi: 10.12890/2023_004042
- Torbicki A, Galie N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ, et al. Right heart thrombi in pulmonary embolism. J Am Coll Cardiol 2003;41:2245–2251. doi: 10.1016/S0735-1097(03)00479-0
- Shiota M, Kotani Y, Umemoto M, Tobiume T. Deep-vein thrombosis is associated with large uterine fibroids. Tohoku J Exp Med 2011;224:87–91. doi: 10.1620/tjem.224.87
