Acute pulmonary thromboembolism is a pulmonary pathology that is becoming more frequent nowadays, the use of new mechanical and thrombolytic therapies has a significant impact on the cardiopulmonary prognosis.

A 41-year-old male, a retired military man, smoking, overweight, dyslipidemia, alcoholic liver disease, who attended the emergency department due to abrupt dyspnea, with tachycardia, chest pain, and syncope; the patient had tachycardia of 120 bpm, BP 90/60mmHg and SO₂ of 82%, with a history of COVID-19 infection, suspected of massive pulmonary embolism, it was decided to carry out computed tomography where a bilateral submassive pulmonary embolism was documented (Fig. 1A), it was proposed to perform systemic thrombolysis, however due to the risk of bleeding, it was decided to perform EKOS ultrasound directed thrombolysis. Baseline pulmonary angiography was performed with a large number of thrombi (Fig. 1B), distributed in both main right and left branches and deficient pulmonary filling of distal vessels, due to the large amount of thrombus, it was decided to perform manual thrombus aspiration, obtaining a large amount of thrombus (Fig. 1C), as well as thrombolysis in situ with Alteplase a dose of 1mg/catheter/hour for 12hours, with a total dose of 24mg; Ultrasound probe was placed in both pulmonary arteries with the EKOS system (Fig. 1D).

Pulmonary angiography was performed 24hours after the procedure, where no bleeding occurred and almost complete resolution of the thrombus was observed. The patient later with 92% SO₂, without oxygen requirements, with HR 90 bpm, with no evidence of ventricular dysfunction, was discharged home with anticoagulation.

Low dose fibrinolysis and thromboaspiration are considered, as well as the use of EKOS endovascular ultrasound, a safe and effective procedure, in the context of a patient with high-risk of bleeding, with favorable results that condition clinical and prognostic improvement.