Use of Rheolytic Thrombectomy in Treatment of Acute Massive Pulmonary Embolism

Technical Aspects of Penumbra Indigo Lightning Flash System for Mechanical Thrombectomy of Pulmonary Embolism: A Comprehensive Review

PURPOSE

To demonstrate the technical aspects of the novel Penumbra Indigo Lightning Flash System (Penumbra, Inc.) for mechanical thrombectomy of pulmonary embolism (PE).

TECHNIQUE

The novel Penumbra Lightning Flash catheter is a 16 French (F) sheath-compatible device designed for advanced thrombectomy, especially in the pulmonary arteries. This device has large thrombus burden removal capacity; however, technical nuances are necessary to accomplish more with efficacy pulmonary embolism management. Access sites, pulmonary arteries catheterization technique, thrombectomy device navigation and mechanism of action are described thoroughly.

CONCLUSION

Penumbra Indigo Lightning Flash system for mechanical thrombectomy as other catheter-directed treatments (CDTs) represents a major advance in contemporary PE management. With favorable safety profile and efficacy, CDTs have become an integral component of the multidisciplinary approach to PE care.

CLINICAL IMPACT

The article highlights the Penumbra Indigo Lightning Flash System as a significant advancement in mechanical thrombectomy for pulmonary embolism (PE). By detailing technical aspects and procedural nuances, it supports clinicians for improvement in endovascular PE management. The system's integration into multidisciplinary care represents a major step forward, providing an effective alternative to traditional therapies, particularly for high-risk PE patients. This innovation promises to enhance patient outcomes in contemporary PE management.

Percutaneous interventions for pulmonary embolism

Pulmonary embolism (PE) ranks as a leading cause of in-hospital mortality and the third most common cause of cardiovascular death. The spectrum of PE manifestations varies widely, making it difficult to determine the best treatment approach for specific patients. Conventional treatment options include anticoagulation, thrombolysis, or surgery, but emerging percutaneous interventional procedures are being investigated for their potential benefits in heterogeneous PE populations. These novel interventional techniques encompass catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches combining different mechanisms. Furthermore, inferior vena cava filters are also available as an option for PE prevention. Such interventions may offer faster improvements in right ventricular function, as well as in pulmonary and systemic haemodynamics, in individual patients. Moreover, percutaneous treatment may be a valid alternative to traditional therapies in high bleeding risk patients and could potentially reduce the burden of mortality related to major bleeds, such as that of haemorrhagic strokes. Nevertheless, the safety and efficacy of these techniques compared to conservative therapies have not been conclusively established. This review offers a comprehensive evaluation of the current evidence for percutaneous interventions in PE and provides guidance for selecting appropriate patients and treatments. It serves as a valuable resource for future researchers and clinicians seeking to advance this field. Additionally, we explore future perspectives, proposing "percutaneous primary pulmonary intervention" as a potential paradigm shift in the field.

Percutaneous Management of High-Risk Pulmonary Embolism

Acute pulmonary embolism (PE) leads to an abrupt increase in pulmonary vascular resistance and right ventricular afterload, and when significant enough, can result in hemodynamic instability. High-risk PE is a dire cardiovascular emergency and portends a poor prognosis. Traditional therapeutic options to rapidly reduce thrombus burden like systemic thrombolysis and surgical pulmonary endarterectomy have limitations, both with regards to appropriate candidates and efficacy, and have limited data demonstrating their benefit in high-risk PE. There are growing percutaneous treatment options for acute PE that include both localized thrombolysis and mechanical embolectomy. Data for such therapies with high-risk PE are currently limited. However, given the limitations, there is an opportunity to improve outcomes, with percutaneous treatments options offering new mechanisms for clot reduction with a possible improved safety profile compared with systemic thrombolysis. Additionally, mechanical circulatory support options allow for complementary treatment for patients with persistent instability, allowing for a bridge to more definitive treatment options. As more data develop, a shift toward a percutaneous approach with mechanical circulatory support may become a preferred option for the management of high-risk PE at tertiary care centers.

Extracorporeal Membrane Oxygenation—First Strategy for Acute Life-Threatening Pulmonary Embolism

Background

Both venoarterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous mechanical thrombectomy (PMT) are increasingly used to treat acute life-threatening pulmonary embolism (PE). However, there are little data regarding their effectiveness. This study aimed to present the short-term outcomes after managing nine patients with acute life-threatening massive or submassive PE by VA-ECMO with or without complemented PMT and propose a preliminary treatment algorithm.

Methods

This study was a single-center retrospective review of a prospectively maintained registry. It included nine consecutive patients with massive or submassive pulmonary embolism who underwent VA-ECMO for initial hemodynamic stabilization, with or without PMT, from August 2018 to November 2021.

Results

Mean patient age was 54.7 years. Four of nine patients (44.4%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All cannulations (100%) were successfully performed percutaneously. Overall survival was 88.9% (8 of 9 patients). One patient died from a hemorrhagic stroke. Of the survivors, the median ECMO duration was 8 days in patients treated with ECMO alone and 4 days in those treated with EMCO and PMT. Five of nine patients (55.6%) required concomitant PMT to address persistent right heart dysfunction, with the remaining survivors (44.4%) receiving VA-ECMO and anticoagulation alone. For survivors receiving VA-ECMO plus PMT, median hospital lengths of stay were 7 and 13 days, respectively.

Conclusions

An ECMO-first strategy complemented with PMT can be performed effectively and safely for acute life-threatening massive or submassive PE. VA-ECMO is feasible for initial stabilization, serving as a bridge to therapy primarily in inoperable patients with massive PE. Further evaluation in a larger cohort of patients is warranted to assess whether VA-ECMO plus PMT may offer an alternative or complementary therapy to thrombolysis or surgical thrombectomy.

Type of Research

Single-center retrospective review of a prospectively maintained registry.

Meta-Analysis of the Usefulness of Inferior Vena Cava Filters in Massive and Submassive Pulmonary Embolism

To conduct a systematic review and meta-analysis evaluating the safety and effectiveness of inferior vena cava filter (IVCF) placement in the setting of massive and submassive pulmonary embolism (PE), Pubmed and Cochrane Library were queried to identify all clinical studies evaluating IVCF placement in patients with massive and submassive PE from database establishment to December 2019. The rate of recurrent PE, PE-related mortality, adverse events, IVCF type, additional treatment intervention, DVT status, and follow-up length were retrieved. Recurrent PE, mortality, and complication rates were pooled. Meta-analysis was performed to compare mortality rates between groups with and without IVCF placement. Subgroup analysis was performed based on whether catheter-directed therapy was used for PE intervention. Fifteen observational studies with a total of 232 patients who received IVCF for submassive or massive PE were included. The pooled overall recurrent symptomatic PE and mortality rates were 1.4% and 5.5%, respectively. A lower mortality rate among patients with IVCF was observed than those without (6.8% vs 26.3%; odds ratio [OR] 0.275 [95% confidence interval] 0.090 to 0.839], I² = 30.6%, p = 0.023). Patients who received concurrent catheter-directed therapy demonstrated a lower recurrent PE (0% vs 2.8%) and mortality rate (3.4% vs 7.8%) than those who did not. The cumulative IVCF-related complication rate was 0.63%. In conclusion, based on a limited amount of low-quality evidence, IVCF placement is associated with low recurrent PE and PE-related mortality rates among patients with massive and submassive PE, suggestive of a potential clinical benefit in this scenario. Prospectively designed studies are warranted to confirm these findings.

Catheter-based therapies in acute pulmonary embolism

AIMS

To provide a systematic review of catheter-based therapies of acute pulmonary embolism.

METHODS AND RESULTS

Studies published in peer-reviewed journals before February 2017 were included and categorized according to the mechanism of thrombus removal: fragmentation, rheolytic therapy, aspiration or catheter-directed thrombolysis. Strengths, challenges and the level of evidence of each device were evaluated. We found 16 different catheter-based therapies for acute PE; all but one being used off-label. The majority of procedures involve catheter-directed thrombolysis. Aspiration therapy shows promise, but limited data are available. Rheolytic therapy should be used with caution, if at all, due to the high number of associated complications.

CONCLUSIONS

Catheter-based therapies show promise as a treatment for acute PE, though evidence is lacking. Further research into the efficacy and safety of devices is needed.

Lifting the fog in intermediate-risk (submassive) PE: full dose, low dose, or no thrombolysis?

Acute pulmonary embolism (PE) is a disease frequently encountered in clinical practice. While the management of haemodynamically stable, low risk patients with acute PE is well established, managing intermediate disease often presents a therapeutic dilemma. In this review, we discuss the various therapeutic options available in this patient group. This includes thrombolysis, surgical embolectomy and catheter directed techniques. We have also explored the role of specialist PE response teams in the management of such patients. ​.

Pulmonary tumor embolism secondary to soft tissue and bone sarcomas: a case report and literature review

Background

Tumor embolisms (TE) are an underappreciated source of pulmonary embolisms in sarcoma. Most evidence in the literature is limited to case reports and none have described the presence of TE secondary to myxofibrosarcoma. We report the first case of myxofibrosarcoma TE and perform a review of the literature for TE secondary to bone and soft tissue sarcomas (STS).

Case presentation

A 36-year-old female presented with debilitating pain of the right upper extremity secondary to a recurrent soft tissue sarcoma. She had distant metastasis to the lung. An MRI revealed a 25-cm shoulder mass involving the proximal arm muscles with encasement of the axillary artery, vein, and brachial plexus. A palliative forequarter amputation was performed and tumor thrombus was evident within the axillary artery and vein. Postoperatively, she developed an acute onset of dyspnea and hypoxia. A computed tomography scan revealed a pulmonary saddle embolism. A bilateral lower extremity venous duplex was negative. She became hemodynamically unstable despite resuscitation and was placed on vasopressor support. A transthoracic echocardiogram revealed elevated pulmonary artery pressure, tricuspid regurgitation, right heart dilation, and reduced right heart systolic function consistent with acute cor pulmonale. The patient did not want to pursue a median sternotomy with pulmonary artery embolectomy and expired from cardiopulmonary arrest within 24 h of the operation. The final pathology revealed a 25 × 16 × 13 cm high-grade myxofibrosarcoma with invasion into the bone, skin, and neurovascular bundle as well as evidence of tumor thrombus.

Conclusion

TE is a rare but deadly cause of pulmonary embolism in sarcoma. A high index of suspicion is necessary in individuals who present with respiratory-related symptoms, especially dyspnea. Diagnostic confirmation with a computed tomography scan of the chest and echocardiogram should be rapid. Unlike venous thromboembolism, pulmonary embolectomy remains the preferred therapeutic approach.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-017-1223-3) contains supplementary material, which is available to authorized users.

Catheter-Directed Therapy in Acute Pulmonary Embolism with Right Ventricular Dysfunction: A Promising Modality to Provide Early Hemodynamic Recovery

BACKGROUND Catheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure. MATERIAL AND METHODS Medical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed. RESULTS The study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2 ± 16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04-0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2-98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure. CONCLUSIONS CDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

Treatment of Massive or Submassive Acute Pulmonary Embolism With Catheter-Directed Thrombolysis

The presentation of acute pulmonary thromboembolism (PE) can be highly variable resulting in diagnostic challenges and management difficulties. Current guidelines suggest that therapy must be adjusted based on the severity of PE presentation. Systemic thrombolysis is the standard therapy for acute massive PE; however, systemic thrombolysis carries an estimated 20% risk of major hemorrhage, including a 3% to 5% risk of hemorrhagic stroke. There are data supporting the use of catheter-directed therapy (CDT) in massive and submassive PE, but past studies have limited its use to patients in whom systemic thrombolysis has either failed or was contraindicated. There is a paucity of data comparing the efficacy of CDT compared to systemic thrombolysis in different risk groups. This review will summarize the available data on the techniques and indications and outcomes of CDT for acute PE.

Unsuccessful percutaneous mechanical thrombectomy in fibrin-rich high-risk pulmonary thromboembolism

Background

We report a case of unsuccessful percutaneous mechanical thrombectomy in treatment of a high-risk pulmonary embolism (PE). Pulmonary thromboemboli are commonly expected as a homogenous mass, rich with red blood cell content, which respond well to percutaneous mechanical thrombectomy (PMT). Catheter-based approach or surgical embolectomy are two treatment options that are usually considered for treatment of high-risk PE when the thrombolytic therapy fails or it is contraindicated due to a patient’s persisting hemodynamic compromise. Currently, selection criteria for PE treatment options are based mostly on the assessment of patient’s history. The aim of this report is to highlight a possible treatment complication in PMT of structurally heterogeneous thrombotic mass due to PMT inadequacy.

Case presentation

A 32 year-old male with polytrauma was admitted to an intensive care unit after a right-sided nephrectomy and evacuation of retroperitoneal hematoma. The patient initial haemostatic disorder was improved by administration of blood preparations, an anti-fibrinolytic agent and concentrates of fibrinogen. On the third day he presented sudden onset of hemodynamic instability and was incapable of standard CTA diagnostic procedure. Urgent and relevant investigations including transthoracic and transesophageal echocardiogram confirmed a high-risk PE. PMT was performed due to contraindications for systemic thrombolysis. Long-term PMT was attempted using aspiration with several devices. No major improvement was achieved in any of the treatments and the patient died. Autopsy confirmed a large heterogeneous thrombotic mass in the pulmonary trunk folding to the right main artery. Additional histological analysis revealed a high fibrin-rich content in the peripheral surroundings of the thrombus.

Conclusion

In the case, it was confirmed that the outcome of PMT was directly influenced by mechanical and histological features of the thromboembolus in high-risk PE. Formation of a rather complex thromboembolus in high-risk PE favors surgical embolectomy as the only life-saving treatment option. Current diagnostic imaging techniques do not enable precise assessment of thrombi structure and are therefore unable to identify patients who might benefit from PMT or open surgical embolectomy. Surgical backup treatment should be considered if there are no contraindications in the event of a failed catheter intervention.

Management of pulmonary embolism with rheolytic thrombectomy

BACKGROUND

Catheter thrombectomy combining thrombus destruction with local thrombolysis has been used in patients with pulmonary embolism (PE) who are unstable or have significant right heart dysfunction, but have contraindications to systemic thrombolytic therapy.

OBJECTIVES

To assess the outcomes of patients who underwent pulmonary embolectomy using a commercially available thrombectomy device.

METHODS

A retrospective chart review of patients who underwent pulmonary embolectomy between March 2007 and August 2009 was performed. Patients were classified as having clinical massive or submassive PE, and moderate or severe right ventricular dysfunction. Data collected included pre- and postprocedure shock index (heart rate divided by systolic blood pressure) and mean pulmonary artery pressure.

RESULTS

Sixteen patients with a mean (± SD) age of 54.4 ± 15.8 years underwent embolectomy. Five had clinical massive PE (two in cardiogenic shock) and three of 11 submassive cases had severe right ventricular dysfunction. All were deemed to have contraindications to systemic lysis. Both shock index (1.02 ± 33 preintervention versus 0.71 ± 0.2 postintervention [P=0.001]) and mean pulmonary artery pressure (34.5 ± 9.9 mmHg preintervention versus 27.1 ± 7.1 postintervention [P=0.01]) improved. In the massive PE group, one patient died and two survivors experienced retroperitoneal bleeding and transient renal failure. At follow-up (17.3 ± 7.8 months), two patients in the massive PE group demonstrated evidence of mild cor pulmonale.

CONCLUSION

Rheolytic thrombectomy is an effective strategy in managing massive PE, particularly in patients who have well-defined contraindications to systemic lytic therapy. The effectiveness of rheolytic thrombectomy for submassive PE is not as well defined, but warrants a comparison with systemic lytic therapy.

Aggressive management of pulmonary embolism

Pulmonary embolism (PE) and deep vein thrombosis are two elements of the same pathophysiological process referred to as venous thromboembolism. PE occurs when a thrombus migrates from a deep vein to the pulmonary arteries. Although the true incidence of PE is not known, it is estimated that 530,000 cases of PE occur annually in the United States. Clinical presentation varies from asymptomatic (incidentally diagnosed) to fatal. Development of symptoms depends on the embolic burden and the severity of any underlying cardiopulmonary disease. Several treatment options are available for patients diagnosed with PE. The mainstay of treatment is anticoagulation, but given the high mortality associated with some presentations of symptomatic PE, some advocate more aggressive therapy. In this article we discuss such therapies and their potential and appropriate use.

Rheolytic Thrombectomy with or without Adjunctive Indwelling Pharmacolysis in Patients Presenting with Acute Pulmonary Embolism Presenting with Right Heart Strain and/or Pulseless Electrical Activity

Purpose. To evaluate the safety and efficacy of the Possis rheolytic thrombectomy with or without indwelling catheter-directed pharmacolysis for the treatment of massive pulmonary embolus in patients presenting with right heart strain and/or a pulseless electrical activity (PEA). Materials and Methods. Retrospective review of patients undergoing pulmonary pharmacolysis was performed (07/2004-06/2009). Pre- and posttreatment Miller index scoring weres calculated and compared. Patients were evaluated for tPA doses, ICU stay, hospital stay, and survival by Kaplan-Meier analysis. Results. 11 patients with massive PE were found, with 10/11 presenting with a Miller score of >17 (range: 16-27, mean: 23.2). CTPA and/or echocardiographic evidence of right heart strain was found in 10/11 patients. 3 (27%) patients presented with a PEA event. Two (18%) patients had a contraindication to pharmacolysis and were treated with mechanical thrombectomy alone. The intraprocedural mortality was 9% (n = 1/11). Of the 10 patients who survived the initial treatment, 7 patients underwent standard mechanical thrombectomy initially, while 5 received power pulse spray mechanical thrombectomy. Eight of these 10 patients underwent adjunctive indwelling catheter-directed thrombolysis. The mean catheter-directed infusion duration was 18 hours (range of 12-26 hours). The average intraprocedural, infusion, and total doses of tPA were 7 mg, 19.7 mg, and 26.7 mg, respectively. There was a 91% (10/11) technical success rate. The failure was the single mortality. Average reduction in Miller score was 9.5 or 41% (P = 0.009), obstructive index of 6.4 or 47% (P = 0.03), and perfusion index of 2.7 or 28% (P = 0.05). Average ICU and hospital stay were 7.4 days (range 2-27 days) and 21.3 days (range 6-60 days), respectively. Intent to treat survival was 90% at 6, 12, and 18 months. Conclusion. Rheolytic thrombectomy with or without adjunctive catheter-directed thrombolysis provides a safe and effective method for treatment of acute PE in patients who present with right heart strain and/or a PEA event.

Endovascular therapy for acute pulmonary embolism

Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with massive PE (defined by hemodynamic shock) as well as in many patients with submassive PE (defined by right ventricular strain). The best current evidence suggests that modern catheter-directed therapy to achieve rapid central clot debulking should be considered as an early or first-line treatment option for patients with acute massive PE; and emerging evidence suggests a catheter-directed thrombolytic infusion should be considered as adjunctive therapy for many patients with acute submassive PE. This article reviews the current approach to endovascular therapy for acute PE in the context of appropriate diagnosis, risk stratification, and management of acute massive and acute submassive PE.

Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques

PURPOSE

Systemic thrombolysis for the treatment of acute pulmonary embolism (PE) carries an estimated 20% risk of major hemorrhage, including a 3%-5% risk of hemorrhagic stroke. The authors used evidence-based methods to evaluate the safety and effectiveness of modern catheter-directed therapy (CDT) as an alternative treatment for massive PE.

MATERIALS AND METHODS

The systematic review was initiated by electronic literature searches (MEDLINE, EMBASE) for studies published from January 1990 through September 2008. Inclusion criteria were applied to select patients with acute massive PE treated with modern CDT. Modern techniques were defined as the use of low-profile devices (< or =10 F), mechanical fragmentation and/or aspiration of emboli including rheolytic thrombectomy, and intraclot thrombolytic injection if a local drug was infused. Relevant non-English language articles were translated into English. Paired reviewers assessed study quality and abstracted data. Meta-analysis was performed by using random effects models to calculate pooled estimates for complications and clinical success rates across studies. Clinical success was defined as stabilization of hemodynamics, resolution of hypoxia, and survival to hospital discharge.

RESULTS

Five hundred ninety-four patients from 35 studies (six prospective, 29 retrospective) met the criteria for inclusion. The pooled clinical success rate from CDT was 86.5% (95% confidence interval [CI]: 82.1%, 90.2%). Pooled risks of minor and major procedural complications were 7.9% (95% CI: 5.0%, 11.3%) and 2.4% (95% CI: 1.9%, 4.3%), respectively. Data on the use of systemic thrombolysis before CDT were available in 571 patients; 546 of those patients (95%) were treated with CDT as the first adjunct to heparin without previous intravenous thrombolysis.

CONCLUSIONS

Modern CDT is a relatively safe and effective treatment for acute massive PE. At experienced centers, CDT should be considered as a first-line treatment for patients with massive PE.

Treatment of massive pulmonary embolism utilizing a multidisciplinary approach: a case study

Massive pulmonary embolism (PE) is associated, historically, with a high mortality rate.Treatment options include systemic anticoagulation, catheter-directed thrombolytic therapy, surgical embolectomy, fragmentation techniques, and catheter embolectomy. Extracorporeal membrane oxygenation (ECMO) repeatedly has demonstrated effectiveness in providing cardiopulmonary support for the patient with a massive PE too unstable to undergo thrombolysis or embolectomy. The present case study describes a morbidly obese patient, status post gastric bypass surgery, who presented with PE, and acute respiratory and cardiac failure. A description of the patient’s management plan, which includes a simple, rapidly deployed ECMO system (Levitronix® CentriMag® and Jostra Quadrox D), systemic- and catheter-directed thrombolytic therapy and rheolytic thrombectomy (AngioJet® Series 3000, Possis Medical, Minneapolis, MN).

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism

OBJECTIVES

To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE).

BACKGROUND

The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate.

METHODS

We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index >or= 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all-cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT.

RESULTS

Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in-hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long-term follow-up (35.5 +/- 21.7 months) except three who expired due to cancer and acute myocardial infarction.

CONCLUSIONS

In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed.

Acute kidney injury caused by intravascular hemolysis after mechanical thrombectomy

BACKGROUND

A 43-year-old African-American female (gravida 5 para 0) with an 8-week intrauterine pregnancy presented to the emergency room with crampy abdominal pain, shortness of breath, and shoulder pain. She had normal renal function on admission. CT angiography of the chest revealed bilateral pulmonary emboli; therefore, the AngioJet (Possis Medical, Inc., Minneapolis, MN) device was used to perform mechanical thrombolysis. The patient subsequently developed hyperkalemia, red urine and anuria.

INVESTIGATIONS

Physical examination, measurement of serum creatinine level and electrolytes, dipstick urinalysis and centrifugation of urine and blood.

DIAGNOSIS

Acute kidney injury due to hemoglobinuria as a result of non-immune-mediated intravascular hemolysis following the use of a percutaneous mechanical thrombectomy device (AngioJet).

MANAGEMENT

Hydration, alkalinization of urine and initiation of hemodialysis (temporarily switched to continuous venovenous hemodiafiltration). Urine output improved after the 20th day of hospitalization, at which point dialysis was discontinued. The patient's renal function completely recovered by day 25.

Mechanical and Enzymatic Thrombolysis of Acute Pulmonary Embolus: Review of the Literature and Cases from Our Institution

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Patients with massive PE have a high mortality rate, with two of every three deaths occurring in the first hour. The mainstay of treatment for PE is anticoagulation. However, when the patient is in extremis, intravenous lysis of the clot is indicated. Recently, mechanical fragmentation with or without pharmacologic thrombolysis has been shown to have a role in therapy for patients with massive PE, as well as in those patients who have a contraindication to anticoagulation. We discuss our experience with mechanical fragmentation in the treatment of PE and review the literature.

Rheolytic thrombectomy in patient with massive pulmonary embolism: a case report and review of literature

OBJECTIVE

Despite advances in management with thrombolytic therapy or open embolectomy, the mortality rate remains high in patients with massive pulmonary embolism (MPE).

BACKGROUND

We present a case of 51-year-female patient who collapsed while jogging and was brought to the Emergency Department. Upon arrival, she was found to have marked hypotension and hypoxia. EKG showed marked ST T abnormalities suggestive of anterior and lateral ischemia. Blood was drawn for labs. Patient received aspirin, heparin, and was transferred to cardiac catheterization laboratory.

METHODS

Coronary angiogram revealed normal epicardial coronaries. A pigtail catheter was inserted through right femoral vein and pulmonary angiogram was performed. It revealed bilateral MPE. Tissue plasminogen activator was initiated as per standard protocol. A 7-French aspiration catheter (Export, Medtronic Vascular, Santa Rosa, CA) was used without any success. Rheolytic thrombectomy (RT) (AngioJet, Possis, Minneapolis, MN) was performed successfully with adjunctive local and systemic thrombolytic therapy. Immediate pulmonary angiogram showed increased perfusion through right pulmonary artery. Her hemodynamic status improved significantly. Patient was discharged home after 8 days of hospitalization. Patient remains on lifelong anticoagulation therapy and she continues to remain stable at 20 months follow up.

CONCLUSIONS

RT with adjunctive localized and systematic thrombolytic therapy was performed successfully in this patient with MPE and significant hemodynamic compromise. In our patient who was very unstable from cardio-respiratory perspective with maximized hemodynamic support, RT device use was life saving. RT has an advantage of not dispersing emboli particles to the distal pulmonary circulation.

Early and long-term clinical results of AngioJet rheolytic thrombectomy in patients with acute pulmonary embolism

Anticoagulant and thrombolytic therapies are a mainstay in the management of acute pulmonary embolism (PE), especially when hemodynamic compromise is present. However, systemic drugs cannot achieve timely and effective treatment of acute PE in all patients. In such a setting, mechanical removal of thrombus from the pulmonary circulation holds the promise of significant clinical benefits, although it remains untested. We report early and long-term outcome of patients with massive or submassive acute PE treated with rheolytic thrombectomy by means of the 6Fr Xpeedior AngioJet device at our institution. Three main groups were defined pre hoc: subjects with severe (i.e., shock), moderate, or mild hemodynamic compromise. Technical and procedural successes, obstruction, perfusion and Miller indexes, and clinical events were appraised. In total 25 patients were treated with thrombectomy (8 in severe, 12 in moderate, and 5 in mild hemodynamic compromise). Technical and procedural successes were obtained in all patients, as confirmed by the significant improvement in obstruction, perfusion and Miller indexes overall, and in each subgroup (all p values <0.001). Improvement in obstruction, perfusion, and Miller indexes at the end of the procedure could also be confirmed in patients (n = 8) treated with local fibrinolysis and in the absence of concomitant thrombolysis (n = 17, p <0.05). Four patients died in hospital, all other patients but 1 were safely discharged after an appropriate hospital stay, and all were alive at long-term follow-up (median 61 months). In conclusion, this study supports at early and long-term follow-up the effectiveness and safety of rheolytic thrombectomy for PE.

Percutaneous mechanical thrombectomy for the treatment of acute massive pulmonary embolism: case report

BACKGROUND

To our knowledge we report the first case of percutaneous mechanical thrombectomy used for the treatment of massive pulmonary embolism in the United Kingdom. Pulmonary embolism is a common disease process but can be difficult to diagnose. Massive pulmonary embolism presenting with profound hypotension, however, is rare. Both phenomena carry with them significant mortality. Traditionally those patients suffering haemodynamic compromise from pulmonary embolism are treated with intravenous or catheter-directed thrombolysis. When this is contraindicated surgical embolectomy or mechanical techniques via a right heart catheter are alternative options. The former is well established but the latter is less commonly utilised in clinical practice. Our aim is to highlight the effectiveness and relative safety of percutaneous mechanical thrombectomy as a therapeutic tool in massive pulmonary embolism.

CASE PRESENTATION

A 70 year-old gentleman presented with a 4-month history of dry cough and general malaise. Clinical examination along with routine chest radiograph confirmed a left pleural effusion which was drained. Computed tomography of the chest, abdomen and pelvis revealed a left renal mass consistent with renal cell carcinoma plus multiple metastatic subpleural nodules. Following planned thoracoscopy and pleural biopsy the patient became acutely dyspnoeic and hypotensive. Relevant investigations including computed tomography pulmonary angiogram confirmed a large saddle embolus extending in to the lobar branches of both left and right pulmonary arteries. There were several relative contraindications to thrombolysis and so the patient proceeded to have percutaneous mechanical thrombectomy with excellent results. The patient made a full recovery from the acute episode and was discharged home on warfarin with a view to planned cyto-reductive nephrectomy.

CONCLUSION

We illustrate here that percutaneous mechanical thrombectomy can be a safe and effective method of treating massive pulmonary embolism when thrombolysis is relatively contraindicated. It may also be of use as an adjuvant therapy in those patients able to receive thrombolysis. In the future further evaluation involving a larger cohort of subjects is necessary to determine whether this treatment is superior to surgical embolectomy when thrombolysis cannot be performed.

Management strategies for patients with pulmonary hypertension in the intensive care unit

OBJECTIVE

Pulmonary hypertension may be encountered in the intensive care unit in patients with critical illnesses such as acute respiratory distress syndrome, left ventricular dysfunction, and pulmonary embolism, as well as after cardiothoracic surgery. Pulmonary hypertension also may be encountered in patients with preexisting pulmonary vascular, lung, liver, or cardiac diseases. The intensive care unit management of patients can prove extremely challenging, particularly when they become hemodynamically unstable. The objective of this review is to discuss the pathogenesis and physiology of pulmonary hypertension and the utility of various diagnostic tools, and to provide recommendations regarding the use of vasopressors and pulmonary vasodilators in intensive care.

DATA SOURCES AND EXTRACTION

We undertook a comprehensive review of the literature regarding the management of pulmonary hypertension in the setting of critical illness. We performed a MEDLINE search of articles published from January 1970 to March 2007. Medical subject headings and keywords searched and cross-referenced with each other were: pulmonary hypertension, vasopressor agents, therapeutics, critical illness, intensive care, right ventricular failure, mitral stenosis, prostacyclin, nitric oxide, sildenafil, dopamine, dobutamine, phenylephrine, isoproterenol, and vasopressin. Both human and animal studies related to pulmonary hypertension were reviewed.

CONCLUSIONS

Pulmonary hypertension presents a particular challenge in critically ill patients, because typical therapies such as volume resuscitation and mechanical ventilation may worsen hemodynamics in patients with pulmonary hypertension and right ventricular failure. Patients with decompensated pulmonary hypertension, including those with pulmonary hypertension associated with cardiothoracic surgery, require therapy for right ventricular failure. Very few human studies have addressed the use of vasopressors and pulmonary vasodilators in these patients, but the use of dobutamine, milrinone, inhaled nitric oxide, and intravenous prostacyclin have the greatest support in the literature. Treatment of pulmonary hypertension resulting from critical illness or chronic lung diseases should address the primary cause of hemodynamic deterioration, and pulmonary vasodilators usually are not necessary.

Catheter Embolectomy for Acute Pulmonary Embolism

Massive pulmonary embolism (PE) is a life-threatening condition with a high early mortality rate due to acute right ventricular failure and cardiogenic shock. As soon as the diagnosis is suspected, an IV bolus of unfractionated heparin should be administered. In addition to anticoagulation, rapid initiation of systemic thrombolysis is potentially life-saving and therefore is standard therapy. Many patients with massive PE cannot receive thrombolysis because of an increased bleeding risk, such as prior surgery, trauma, or cancer. In these patients, catheter or surgical embolectomy are helpful for rapidly reversing right ventricular failure. Catheter thrombectomy appears to be particularly useful if surgical embolectomy is not available or the patient has contraindications to surgery. Although no controlled clinical trials are available, data from cohort studies indicate that the clinical outcomes after surgical and catheter embolectomy may be comparable.

Pulmonary Embolism in the Critically Ill

Pulmonary embolism in the critically ill requires considerations beyond anticoagulant therapy. Measurements of chamber size by echocardiography and CT and of circulating biomarkers identify higher-risk patients with moderate accuracy and may aid determination of patient acuity. Preserving right ventricular function requires judicious use of volume administration, vasopressor, and perhaps vasodilator therapies. Obstructing thrombus can be treated with fibrinolytic drugs, percutaneous instrumentation, or surgically, but these treatments may not be equally effective or safe. Anticoagulant therapy in critically ill patients is likely best administered IV. Bleeding complications should be assiduously sought but do not necessitate anticoagulant discontinuation in every case. The antidotes protamine, desmopressin acetate, factor VIII inhibitory bypass activity, and recombinant factor VIIa may each have a place in controlling anticoagulant-related bleeding. The grave prognosis of heparin-induced thrombocytopenia warrants close surveillance, with rapid switching to lepirudin, argatroban, or fondaparinux necessary if it is suspected. Retrievable vena cava filters can be lifesaving, and at least one type may be safely removed after residence of nearly 1 year.

Catheter-tip embolectomy in the management of acute massive pulmonary embolism

Three catheter interventional techniques are currently available for removing or fragmenting pulmonary emboli: aspiration thrombectomy, fragmentation, and rheolytic thrombectomy. The investigators systematically reviewed all available published research related to the use of catheter-tip devices in patients with pulmonary emboli. Pooled data showed that clinical success with the Greenfield catheter occurred in 72 of 89 patients (81%) when used alone and in 19 of 19 patients (100%) when used in combination with thrombolytic agents. Fragmentation with standard catheters used alone (without thrombolytic agents) was reported in only 3 patients. Clinical success with standard angiographic catheters occurred in 15 of 21 patients (71%) when used in combination with systemic thrombolytic agents and in 115 of 121 patients (95%) when used with local infusions of thrombolytic agents. Data for the Amplatz catheter, the rheolytic Angiojet catheter, and the Hydrolyser catheter when used alone were sparse or absent. Clinical success when used in combination with thrombolytic agents occurred in 6 of 6 patients (100%) with the Amplatz catheter, in 20 of 23 patients (87%) with the Angiojet catheter, and in 19 of 20 patients (95%) with the Hydrolyser catheter. Minor bleeding at the insertion site among all patients, with and without thrombolytic agents, occurred in 29 of 348 patients (8%), and major bleeding at the insertion site occurred in 8 of 348 patients (2%). One patient experienced perforation of the right ventricle with the Greenfield catheter. None reported perforation of a pulmonary artery. In conclusion, all the devices analyzed in this study appear to be useful in the management of acute massive pulmonary emboli.

Bradyarrhythmias during use of the AngioJet system

The AngioJet system is an effective thrombectomy device, but it may cause chest discomfort and provoke bradyarrhythmias that range from mild bradycardia to asystole. The cause of AngioJet-induced bradyarrhythmia is unknown, although several hypotheses have attempted to explain the phenomenon. Herein several cases will be described, followed by a review of the relevant literature. The literature review suggests that the cause may be related to the effects of the hydrodynamic jets on stretch-activated receptors present on the vascular endothelium, and that pretreatment with gadolinium or streptomycin might prevent activation of these receptors.

Rheolytic percutaneous thrombectomy for acute pulmonary embolism in a pediatric patient

Acute massive pulmonary embolism can have significant hemodynamic effects in both adults and children. We describe the case of a 10-year-old boy who developed cardiogenic shock after suffering a massive pulmonary embolism. A significant thrombus burden was removed using a catheter-based strategy of rheolytic thrombectomy, leading to stabilization of the patient.

Percutaneous rheolytic thrombectomy for large pulmonary embolism: A promising treatment option

BACKGROUND

Pulmonary embolism (PE) is a common cardiovascular disease with significant mortality. Some patients with large PE are not eligible for current treatment options such as thrombolysis or surgical embolectomy. We report our experience of percutaneous rheolytic thrombectomy (PRT) using the AngioJet system combined with adjunctive local thrombolytic therapy and inferior vena cava (IVC) filter placement to treat massive or submassive PE in patients ineligible for current treatment options.

METHODS AND RESULTS

Of the 14 consecutive patients ineligible for thrombolysis or embolectomy treated with PRT, 10 patients had massive PE (6 patients were hypotensive and 4 patients had intractable hypoxemia) and 4 patients had submassive PE. Adjunctive local thrombolysis was performed in 5 patients. An IVC filter was placed in 11 patients. Angiographic success based on Miller score was achieved in 13 patients (92.9%). Procedure success was obtained in 12 patients (85.7%). Procedural mortality occurred in one patient who presented in cardiogenic shock (7.1%) and non-fatal hemoptysis occurred in 1 patient (7.1%). Total in-hospital mortality occurred in 3 patients (21.4%). On a mean follow-up of 9 months, all 11 survivors had noted significant improvement in symptoms without recurrence.

CONCLUSIONS

Percutaneous rheolytic thrombectomy using the AngioJet may be a treatment option for patients with massive or submassive PE who may not be eligible for thrombolytic therapy or surgical embolectomy.