A middle-aged patient presented with dyspnoea, haemoptysis and
weight loss following a recent admission for pulmonary
embolus, diagnosed on CT pulmonary angiogram (
CTPA). The patient was anticoagulated with
warfarin to a therapeutic range 2-3. There was no relevant medical history. On examination, the pulse was 105 bpm and blood pressure was 70/50 mm Hg. Oxygen saturation was 94% on air. Repeat
CTPA revealed extension of the clot burden, now a saddle
embolus occluding pulmonary outflow. The patient underwent emergency surgical
embolectomy, and histology of the excised clot revealed the underlying cause--a malignant, high-grade
sarcoma of the pulmonary vasculature. The target international normalised ratio was increased to 3-4. Postoperatively, the patient developed a large malignant
pericardial effusion which required urgent percutaneous drainage. The patient eventually underwent targeted
chemotherapy, which extended patient survival. The patient passed away a year later from progressive
right-sided heart failure as a result of
cor pulmonale.