Traditionally, massive, life-threatening pulmonary embolism (PE) has been treated with systemic thrombolytic therapy while submassive and smaller acute PEs have been treated with systemic anticoagulation therapy. Given that thrombolytic therapy is associated with the risk of life-threatening complications including intracranial hemorrhage, it has not been routinely used or recommended for submassive PEs. In 2017, the Food and Drug administration (FDA) approved ultrasound-facilitated catheter-directed thrombolysis (USCDT) for acute massive and sub-massive pulmonary embolism. USCDT has primarily been performed using jugular or femoral venous access. There have been isolated reports of USCDT performed through upper extremity venous access. We present a case of USCDT in a submassive PE patient with dual right upper extremity venous access where both sheaths were advanced into the basilic vein (due to anatomic variation). Based on recent clinical trial data suggesting that shorted duration USCDT is as effective as longer duration, tissue plasminogen activator (tPA) was infused in this case for 6 hours. This strategy for intervention can enhance patient comfort with USCDT therapy and can be particularly helpful in patients at high risk for access site complications and those unable to lie supine for the long duration of infusion therapy.

Lyme disease is a vector-borne illness of North America and Europe transmitted by Borrelia burgdorferi, over 30,000 cases are reported in the United States yearly. Patients typically present having early localized disease with fevers, headaches, myalgias, and a single erythema migrans. Usually, oral doxycycline is administered with a good disease prognosis but we report the case of a 58-year-old male who presented with Lyme disease diagnosed by immunoassay; he was treated with doxycycline but was refractory and saw an improvement in his symptoms with IV ceftriaxone.

Implantable cardioverter defibrillators (ICD) have become indispensable in managing lifethreatening ventricular arrhythmias. On average, 50%-70% of the patients receive a devicebased therapy within the first two years post implantation. A few patients experience the electrical storm (ES). ES is a syndrome of recurrent ventricular tachycardia or fibrillation occurring two or more times in a 24-hour period, calling for the need of electrical cardioversion or defibrillation to stabilize the patient. We present the case of a patient with severe cardiomyopathy who presented with resistant ES after failing to respond initially to conventional medications like amiodarone and lidocaine. Propofol infusion was not an option due to his severe cardiomyopathy and hypotensive shock state. Aggressive treatment with intravenous medications stabilized his ES and he was eventually transferred to an outside facility for ventricular tachycardia ablation.

Traditionally, massive, life-threatening pulmonary embolism (PE) has been treated with systemic thrombolytic therapy, whereas submassive and smaller acute PEs have been treated with systemic anticoagulation therapy. Given that thrombolytic therapy is associated with a risk of life-threatening complications, including intracranial hemorrhage, it has not been routinely used or recommended for submassive PEs. In 2017, the Food and Drug Administration (FDA) approved ultrasound-facilitated catheter- directed thrombolysis (USCDT) for acute massive and sub-massive pulmonary embolism. USCDT is primarily performed via jugular or femoral venous access. There have been isolated reports of USCDT performed via upper-extremity venous access. We present a case of ultrasound-facilitated catheter-directed thrombolysis (USCDT) in a submassive PE patient with dual right upper extremity venous access, where both sheaths were advanced into the basilic vein (due to anatomic variation). Based on recent clinical trial data suggesting that shorted duration USCDT is as effective as longer duration, tPA was infused in this case for 6 hours. This intervention strategy can enhance patient comfort with USCDT therapy and can be particularly helpful in patients at high risk of access site complications and those unable to lie supine for a long duration of infusion therapy.

No abstract