High-Risk Pulmonary Embolism: A Second Opportunity for Thrombolysis.

Pulmonary embolism (PE) remains a major cause of cardiovascular mortality. High-risk PE is characterized by acute cor pulmonale, persistent hypotension, hypoperfusion, obstructive shock, and, in extreme cases, cardiopulmonary arrest. Systemic thrombolysis is recommended for high-risk PE; however, treatment failure may occur in a subset of patients. Rescue options include surgical embolectomy or a second systemic thrombolysis when hemodynamic instability persists. A 71-year-old woman presented to the hospital with sudden-onset dyspnea and severe hypoxemia. Acute cor pulmonale with obstructive shock was diagnosed, and urgent systemic thrombolysis with Alteplase ® (Boehringer Ingelheim, Germany) was started, with initial improvement. Approximately 15 hours later, there was a new significant clinical deterioration, with refractory shock, severe hypoperfusion, and respiratory failure. In the absence of eligibility for surgical or endovascular intervention, a second systemic thrombolysis was performed, resulting in gradual but progressive clinical recovery. She was discharged from the intensive care unit on day 20, eupneic and without supplemental oxygen. Repeat systemic thrombolysis should be considered in high-risk PE that recurs after a first thrombolysis, when reperfusion strategies, such as endovascular therapy or surgery, are not feasible. This case highlights the potential life-saving role of repeated thrombolysis in select critical-care scenarios.