Rapid Resolution of Pulmonary Embolism and Pacemaker Lead Thrombus With Low-Dose Systemic Thrombolytic Infusion

Pacemaker lead-associated thrombosis is a rare but clinically significant condition that can lead to embolic complications and hemodynamic instability. Management of pacemaker lead-associated thrombi can range from anticoagulation or systemic thrombolysis to catheter-based extraction and surgical removal. In this case, an 80-year-old male patient presented to the Emergency Department (ED) with acute exertional dyspnea and was found to have extensive left lower extremity deep vein thrombosis (DVT), bilateral segmental pulmonary embolism (PE), and a thrombus adhered to the right atrial pacemaker lead. He was treated with low-dose intravenous alteplase infusion as well as heparin in the intensive care unit, leading to rapid thrombus resolution. He was subsequently transitioned to a direct-acting oral anticoagulant (DOAC) and discharged in stable condition. Treatment for pacemaker lead thrombi is not protocolized, given the dependence on various patient-related and situational factors. This case highlights the importance of early recognition and management of pacemaker lead-associated thrombosis and demonstrates a novel treatment approach in the form of low-dose alteplase infusion. Low-dose thrombolytics may be a safer and less invasive treatment modality in hemodynamically stable patients with a high clot burden.