Recurrent Pulmonary Embolism After Pulmonary Endarterectomy During Rivaroxaban Therapy in a Resource-Limited Setting.

backgroundRecurrent pulmonary embolism after endarterectomy despite adequate anticoagulation in high-risk patients remains a significant clinical challenge in low and middle-income countries. CASE SUMMARY: We report the case of 37-year-old man with hyperhomocysteinemia and prior pulmonary endarterectomy who presented with recurrent pulmonary embolism while on rivaroxaban. Imaging demonstrated a large thrombus in the right pulmonary artery with right ventricular dysfunction on echocardiography. In the absence of right heart catheterization, pulmonary hypertension could not be established; therefore, the case was managed as recurrent pulmonary embolism. Given high surgical risk and lack of advanced cardiopulmonary support, the patient was treated with systemic thrombolysis, inferior vena cava filter placement, anticoagulation escalation, and initiation of riociguat. DISCUSSION: This case highlights the challenges of managing recurrent pulmonary embolism in low-resource settings and underscores the importance of individualized therapeutic strategies. TAKE-HOME MESSAGE: Careful risk stratification and switching of anticoagulation should be considered for patients with recurrent pulmonary embolism and hyperhomocysteinemia.