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18 February 2020 : Case report  Saudi Arabia

Thrombolysis in Postoperative Pulmonary Embolism Following Liver Transplantation: A Case Report

Unusual or unexpected effect of treatment

Thamer H. Al-Ghamdi1ABCDEFG*, Anwar Jarrad2AB, Abdalla Younes Bashir3AB, Thomas Lorf4AB, Aiman Obed3ABCG

DOI: 10.12659/AJCR.918857

Am J Case Rep 2020; 21:e918857


BACKGROUND: Postoperative pulmonary embolism following liver transplantations is still one of the most fatal complications, especially during the early postoperative phase. The use of a thrombolytic agent such as the recombinant tissue-type plasminogen activator (rtPA) is considered a contraindication early after major abdominal surgery such as liver transplantation. However, thrombolysis after major surgery in the early postoperative period carries a substantial risk of surgical site hemorrhage.

CASE REPORT: A 55-year-old patient presented with a hepatic mass diagnosed as a combined cholangio/hepatocellular carcinoma. Following the criteria of the University of San Francisco, California (UCSF) for liver transplantation, the case was selected for liver transplantation. The patient received neoadjuvant therapy. After the liver transplantation, on the second postoperative day, an acute, severe dyspnea with sudden onset occurred on the surgical ward. A computed tomography angiography showed a drawn-out embolus, which sprawled into both pulmonary main arteries and occluded them subtotally. A thrombolysis with rtPA was started. Within the first 60 minutes of administration of rtPA, the circulation stabilized effectively, so that epinephrine could be tapered down to zero and the patient was promptly extubated. About 6 hours after administration of rtPA, a sudden and pronounced bleeding via one of the intraperitoneal drains occurred, hemoglobin concentration dropped from 9.7 g/dL to 6.4 g/dL. After immediate re-laparotomy, circulation and hemoglobin concentration were absolutely stable.

CONCLUSIONS: Even with anticipated high risk of bleeding, thrombolysis with rtPA can be used as a life-savings treatment in a case of pulmonary embolism after liver transplantation.

Keywords: Liver Transplantation, Pulmonary Embolism, Tissue Plasminogen Activator, Dyspnea, Fibrinolytic Agents, Middle Aged, Postoperative Complications

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923