Recommended Citation
Ellyin A, Paolella G, Bikeyeva V, et al. The Price of a Pause: PE in a High-Risk Surgical Patient. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Introduction/Background:
Acromegaly is an endocrine disorder characterized by excess growth hormone secretion, typically from a pituitary adenoma, resulting in elevated insulin-like growth factor 1. It is associated with several cardiovascular complications, including hypertension, cardiomyopathy, and arrhythmias. While less commonly recognized, a prothrombotic state may also exist, possibly due to increased thrombin generation and elevated fibrinogen and factor VIII levels. Literature on the risk of venous thromboembolism (VTE) in acromegaly remains sparse, and documented cases of pulmonary embolism (PE) in this population are rare. This case highlights a massive PE in a patient with acromegaly and prior VTE following brief perioperative anticoagulation interruption.
Description:
A 64-year-old male with acromegaly secondary to pituitary adenoma s/p stereotactic radiosurgery, atrial fibrillation, obesity, and a history of recurrent DVT/PE presented for elective thyroidectomy and left parotidectomy. Due to his high thrombotic risk, hematology recommended holding rivaroxaban 24 hours preoperatively, followed by prophylactic enoxaparin postoperatively and resumption of full anticoagulation the next day. He remained intubated overnight due to ventilatory concerns. On postoperative day one, he was extubated and later collapsed while ambulating, suffering a pulseless electrical activity arrest. Return of spontaneous circulation was achieved after 3 minutes of CPR. Bedside ultrasound revealed right ventricular dysfunction, and CT pulmonary angiography confirmed bilateral PE. Systemic thrombolysis was deferred due to recent surgery. He was started on a heparin drip and inhaled nitric oxide and underwent catheter-directed thrombectomy. Post-procedure, he remained in right heart failure requiring vasopressors. He was transferred for evaluation of mechanical support, specifically ECMO, but ultimately improved with medical management. He was discharged on lifelong warfarin, with hematology advising IVC filter placement if anticoagulation interruption is again required.
Discussion:
This case illustrates the thrombotic risk in patients with acromegaly, particularly in the perioperative setting. Even short interruptions in anticoagulation may result in life-threatening PE. A heightened index of suspicion and proactive perioperative planning including interdisciplinary coordination and consideration of bridging or mechanical prophylaxis should be prioritized in high-risk patients with acromegaly and prior VTE.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
Poster
Open Access
Available to all.
The Price of a Pause: PE in a High-Risk Surgical Patient
Introduction/Background:
Acromegaly is an endocrine disorder characterized by excess growth hormone secretion, typically from a pituitary adenoma, resulting in elevated insulin-like growth factor 1. It is associated with several cardiovascular complications, including hypertension, cardiomyopathy, and arrhythmias. While less commonly recognized, a prothrombotic state may also exist, possibly due to increased thrombin generation and elevated fibrinogen and factor VIII levels. Literature on the risk of venous thromboembolism (VTE) in acromegaly remains sparse, and documented cases of pulmonary embolism (PE) in this population are rare. This case highlights a massive PE in a patient with acromegaly and prior VTE following brief perioperative anticoagulation interruption.
Description:
A 64-year-old male with acromegaly secondary to pituitary adenoma s/p stereotactic radiosurgery, atrial fibrillation, obesity, and a history of recurrent DVT/PE presented for elective thyroidectomy and left parotidectomy. Due to his high thrombotic risk, hematology recommended holding rivaroxaban 24 hours preoperatively, followed by prophylactic enoxaparin postoperatively and resumption of full anticoagulation the next day. He remained intubated overnight due to ventilatory concerns. On postoperative day one, he was extubated and later collapsed while ambulating, suffering a pulseless electrical activity arrest. Return of spontaneous circulation was achieved after 3 minutes of CPR. Bedside ultrasound revealed right ventricular dysfunction, and CT pulmonary angiography confirmed bilateral PE. Systemic thrombolysis was deferred due to recent surgery. He was started on a heparin drip and inhaled nitric oxide and underwent catheter-directed thrombectomy. Post-procedure, he remained in right heart failure requiring vasopressors. He was transferred for evaluation of mechanical support, specifically ECMO, but ultimately improved with medical management. He was discharged on lifelong warfarin, with hematology advising IVC filter placement if anticoagulation interruption is again required.
Discussion:
This case illustrates the thrombotic risk in patients with acromegaly, particularly in the perioperative setting. Even short interruptions in anticoagulation may result in life-threatening PE. A heightened index of suspicion and proactive perioperative planning including interdisciplinary coordination and consideration of bridging or mechanical prophylaxis should be prioritized in high-risk patients with acromegaly and prior VTE.
Affiliations
Advocate Lutheran General Hospital