Perioperative management of pulmonary thromboendarterectomy in a patient with life-threatening acute-on-chronic pulmonary thromboembolism secondary to nephrotic syndrome: A case report

A previously healthy 44-year-old man presented with acute severe dyspnea. Laboratory evaluation revealed severe hypoalbuminemia, elevated low-density lipoprotein cholesterol and D-dimer levels, and marked proteinuria, suggesting nephrotic syndrome (NS). Imaging demonstrated bilateral pulmonary emboli with right ventricular strain. Since he developed progressive shock, veno-arterial extracorporeal membrane oxygenation (VA ECMO) and thrombolytic therapy were initiated. Persistent thrombi and failed ECMO weaning due to poor oxygenation prompted urgent pulmonary thromboendarterectomy on day 8, confirming both fresh and organized clots and intimal thickening. The patient was extubated on postoperative day (POD) 3, transferred from intensive care on POD 6, and discharged ambulatory on POD 63. This case represented acute-on-chronic pulmonary thromboembolism (PTE) secondary to previously undiagnosed NS, a condition that predisposes patients to hypercoagulability, including asymptomatic PTE. The case underscores the hazards of NS in acute care settings. Successful management was achieved through coordinated efforts between multidisciplinary specialists and interprofessional collaboration.