Re-administration of thrombolytics in massive pulmonary embolism with initial therapy failure: a case report.

backgroundMassive pulmonary embolism (PE) is a life-threatening emergency with high mortality. Systemic thrombolysis is the standard reperfusion therapy for patients with hemodynamic instability. However, when initial thrombolysis fails, therapeutic options are limited and evidence supporting subsequent interventions is scarce. CASE PRESENTATION: We describe a 45-year-old man with hyperlipidemia and depression who presented with dyspnea, hypoxemia, and cardiogenic shock. Echocardiography revealed right ventricular dilatation and dysfunction, consistent with massive PE. Initial therapy with full-dose alteplase (100 mg) and anticoagulation achieved only transient hemodynamic stabilization. The patient remained severely hypoxemic with persistent right ventricle (RV) dysfunction. As catheter-directed therapy and surgical embolectomy were unavailable, repeat systemic thrombolysis was pursued. A second full dose of alteplase (100 mg) was administered on hospital day four. Within 24 h, oxygen saturation improved from 65% to 92% on room air, and echocardiography confirmed substantial recovery of RV size and function. No major bleeding or other complications occurred during hospitalization.

conclusionCurrent guidelines do not recommend repeat thrombolysis for massive PE unresponsive to initial fibrinolysis, and available evidence is confined to case reports. This case demonstrates that, in carefully selected patients without contraindications, repeat systemic thrombolysis may represent a feasible and potentially lifesaving rescue option, particularly in resource-limited settings where other reperfusion strategies are not available. Further studies are needed to define safety, patient selection, and long-term outcomes.