A 25 year man , hotel manager who had a documented DVT , since 2011 was on tablet warfarin . He discontinued the drug by sheer miscommunication as he was told he should stop the drug beyond INR 3 by his general practitioner.He stopped it permanently instead of titrating the dose of warfain .Six months later he landed in August 2013 with an episode of minor hemoptysis . Clincally he was normal .His lower limbs were fine.
He was investigated and his image file showed .
Living with one lung
- He is comfortable with one lung function (Akin to Pneumonectomy )
- His saturation was 100 % at room air
- Pulse -80/mt .BP 110/80mmhg
- His physical activity did not show any significant limitation (At worst class 2)
One of the cardiac surgery consultant wanted to do pulmonary embolectomy and endarteriectomy .
In fact , he was admitted in the critical care unit driven by the dramatic CT images.
One enthusiastic cardiologist wanted thrombus aspiration and pig tail catheter based thrombolytic irrigation within LPA !
How did we manage ?
- The risk of major vascular surgery was considered high in an absolutely asymptomatic individual .
- Intervention was considered too adventurous.
- He was put on oral anticoagulant with target INR 2.5-3.(After a 1 week Heparin overlap)
- We hope the thrombotic CTO will open up gradually but for surely .As the power of natural lytic molecules should not be underestimated as we have witnessed in LV and LA clot disappearing over months.
- However the option of putting IVC filter was strongly recommended for him , as he has only functioning lung which is threatened by a potential embolus from DVT . The patient wanted to come back for IVC filter next month.
- He was also worked up for all those protein C, S, Lieden mutation stuff.
- The patient was discharged in stable condition (By the way he was never unstable either !)
* Meanwhile the hemoptysis did not recur. CT scan showed a small wedge infarct in left lung that was in the healing mode.
Final message
This is a perfect example of CTO of pulmonary artery being managed conservatively* .We will let you know the follow up .
Link to related topics in this site.
Dr.S.Venkatesan MD 
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