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Anticoagulation with rivaroxaban after ultrasound-assisted catheter-directed thrombolysis in patients with intermediate highrisk pulmonary embolism a case series

Michael Schreinlechner, Markus Theurl, Rudolf Kirchmair, Wolfgang-Michael Franz, Peter Marschang

Background: The optimal treatment for intermediate-high risk pulmonary embolism (PE) is still unclear and challenging. A new method for this entity is ultrasound-assisted catheter directed thrombolysis (USAT). The use of non-vitamin K antagonist anticoagulants (NOAC) is currently not recommended after thrombolysis. In our case series we tried to evaluate the efficacy and safety of NOAC treatment shortly after USAT. Methods and findings: We report five patients with intermediate-high risk pulmonary embolism who were successfully treated with rivaroxaban as post-procedural anticoagulation after USAT. The treatment was tolerated well with rapid clinical improvement and almost complete normalisation of right heart function (reduction of mean right to left ventricular (RV/LV) ratio from 1.22 (range 1.07-1.24) at baseline to 0.87 (range 0.76-1.07) three days after thrombolysis (p = 0.016). We observed one GUSTO moderate bleeding episode and a transient rise in creatinine in one patient, but no other adverse events. After 2.4 days (range 2-4 days), patients were switched from unfractionated heparin to rivaroxaban. Follow up-visit after three months showed normalisation of right heart function (RV/LV ratio 0.69 (range 0.65-0.81), no recurrent thrombotic events and no additional bleeding episodes. Conclusion: In our experience, USAT followed by post-procedural anticoagulation with rivaroxaban appears to be an effective treatment of intermediate-high risk pulmonary embolism.