Large-Bore Mechanical Thrombectomy With Bivalirudin for Post-CABG HIT-Associated Intermediate- to High-Risk Pulmonary Embolism

BACKGROUND: Pulmonary embolism (PE) after coronary artery bypass grafting (CABG) is a rare but high-risk event. Management is challenging when PE occurs with heparin-induced thrombocytopenia (HIT), limiting thrombolytic and heparin-based strategies. CASE SUMMARY: A 59-year-old man developed hypoxemic respiratory failure within 2 weeks after CABG. Computed tomography angiography demonstrated bilateral main and lobar PEs with right-heart strain. HIT was confirmed by studies. Given recent surgery and active HIT, thrombolysis and heparin were contraindicated. He underwent urgent bilateral large-bore mechanical thrombectomy with intraprocedural bivalirudin, resulting in clot reduction and respiratory failure resolution. DISCUSSION: This case demonstrates the feasibility of large-bore mechanical thrombectomy with bivalirudin for post-CABG intermediate- to high-risk PE with HIT. Published experience with exclusive bivalirudin during large-bore pulmonary thrombectomy remains limited, and this case adds to the evidence for postsurgical PE management. TAKE-HOME MESSAGE: Large-bore mechanical thrombectomy may provide effective reperfusion when thrombolysis is contraindicated, with bivalirudin serving as a nonheparin anticoagulant in active HIT.