BACKGROUND: High-risk pulmonary embolism (PE) carries significant mortality, and management becomes complex when it coexists with severe anemia and active bleeding, as thrombolysis is then contraindicated. We report the case of a patient with high-risk PE complicated by severe anemia (hemoglobin 41 g/L) and active uterine bleeding from adenomyosis.

CASE REPORT: A 48-year-old woman presented with haemodynamic instability (blood pressure 74/47 mm Hg), critical anemia (hemoglobin 41 g/L), and a 3-year history of irregular vaginal bleeding from adenomyosis. Computed tomography (CT) pulmonary angiography confirmed bilateral PE with right pulmonary artery main-trunk occlusion; echocardiography showed severe pulmonary hypertension, and duplex ultrasound showed extensive left lower-limb deep vein thrombosis. Thrombolysis was contraindicated. Emergency percutaneous aspiration thrombectomy was performed using large-bore catheters (22F, 20F, 16F) with concurrent inferior vena cava filter placement, reducing pulmonary artery pressure from 51/23 to 34/12 mm Hg; the estimated blood loss, quantified from filtered aspirate, was approximately 100 mL. Adjuncts included transfusion of 13 units of packed red cells, dilatation and curettage, gonadotropin-releasing hormone agonist therapy, and titrated anticoagulation. At discharge after a 24-day hospitalization she was hemodynamically stable, and free of dyspnea, with resolved edema and hemoglobin 72 g/L, on oral rivaroxaban.

CONCLUSIONS: In this thrombolysis-contraindicated patient, aspiration thrombectomy with inferior vena cava filter placement was a feasible rescue strategy that achieved rapid hemodynamic and angiographic improvement without thrombolysis, with palliative rather than curative intent. As a single case, it cannot establish comparative safety or efficacy, and broader conclusions regarding efficacy cannot be drawn. It illustrates a potentially useful approach in similarly complex scenarios where coordinated multidisciplinary care is essential.

Keywords: adenomyosis, Anemia, Pulmonary Embolism, Thrombectomy, Uterine Hemorrhage, Vena Cava Filters