Lung Adenocarcinoma induced pulmonary embolism progression even on anticoagulant treatment

A 45 years old, male patient. He had recently diagnosis of adenocarcinoma on right upper lobe of the lung stage IV. He got bilateral pulmonary embolism as complications of lung adenocarcinoma since 25 days and he was on rivaroxaban 15 mg per day as anticoagulant . At that time of presentation in our ED he did not receive chemotherapy but he got appointment to receive it after 5 days. He presented to our ED for haemoptysis since 20 days and shortness of breath with chest tightness since one day. On exam he had vital signs as heart rate was 100 and oxygen saturation was 97% . ECG was unremarkable, chest x ray showed more white patches in the right lung by the comparison with the previous chest X ray . The CT angio-pulmonary decided that showed more progression in the pulmonary embolism PE . The lab result showed; INR was 3.7, D dime was 6.25 ,PT was 46.2 , otherwise non-significant result . He got admission for embolectomy then the decision change to enoxaparin therapeutic dose. The patient was under care of our oncology team