A 67-year-old male with a past medical history of CHF, MI, hypertension, and diabetes presented to the ED with complaints of headache, chest pain, and dyspnea for the past four days. He stated that he has been without his medications for the past few months due to cost. He denied any past surgical history. He stated that he primarily presented because he felt like “my blood pressure is high”.
Cardiovascular: Tachycardic, 2+ pedal edema bilaterally
Respiratory: Tachypneic, decreased breath sounds bilaterally, ronchi/wheezes bilaterally
Skin: Diaphoretic
Troponin I: 0.13 (elevated)
BNP: 1,504
The findings in this picture are of a phenomenon called clot in transit. Via point-of-care ultrasound we were able to visualize part of a thrombus as it journeyed from the right side of the heart to the lungs, becoming a pulmonary embolism. In studies regarding the subject, clot in transit has been found in 3-18% of patients with acute PE. Unfortunately, clot in transit is associated with higher mortality in patients with acute PE. While not fully understood, part of the reason for this may be related to the fact that the patient population that this finding is found in tends to be sicker with higher rates of CHF, cancer, and immobilization. Additionally, increased mortality may be related to PE size given that the clot must be large enough to be seen by ultrasound. Studies have recorded clot in the 30-day mortality rates for patients with acute PE and visualized clot in transit to be 9-45%.
Take-Home Points
- Point of care US is an essential tool for quickly assessing and appropriately treating patients. This patient’s story was very consistent with a CHF exacerbation but POCUS allowed us to quickly identify a PE and get the patient on track to definitive management.
- Clot in transit once identified requires immediate action because it is associated with such high mortality in patients.
- There remains more research to be done on the matter but it appears that clot in transit signifies a need for advanced forms of PE management (thrombolysis or thrombectomy ) to improve mortality in comparison to normal systemic anticoagulation.
- Athappan G, Sengodan P, Chacko P, Gandhi S. Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis. Vasc Med. 2015 Apr;20(2):131-8. doi: 10.1177/1358863X15569009. PMID: 25832601.
- Barrios D, Rosa-Salazar V, Jiménez D, Morillo R, Muriel A, Del Toro J, López-Jiménez L, Farge-Bancel D, Yusen R, Monreal M; RIETE investigators. Right heart thrombi in pulmonary embolism. Eur Respir J. 2016 Nov;48(5):1377-1385. doi: 10.1183/13993003.01044-2016. Epub 2016 Oct 6. PMID: 27799388.
- FREY J, BROWNBACK K. Clot in transit: A dilema of medical or surgical management. Chest. 2021;160(4):A2190. doi: 10.1016/j.chest.2021.07.1932.
- Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020;187:139-147. doi: 10.1016/ j.thromres.2020.01.006.
Phil Barker, MD
Emergency Medicine
University of Texas - Houston
Latest posts by Phil Barker, MD (see all)
- SAEM Clinical Images Series: Clot in Transit - November 1, 2024
