Integration of catheter thrombectomy into our armamentarium to treat acute pulmonary embolism

Catheter-directed therapy as a treatment for submassive pulmonary embolism: A meta-analysis

AIMS

Catheter-directed therapy (CDT) is included in the guidelines for diagnosing and treating massive pulmonary embolism. However, few studies have evaluated the efficacy of CDT as a treatment for submassive pulmonary embolism (SPE). Therefore, we used evidence-based medicine to evaluate the effectiveness and safety of CDT in treating SPE.

METHODS

Search terms describing CDT in SPE and patients with intermediate pulmonary embolism were entered into the PubMed, Embase and Cochrane Library databases to identify relevant articles without language restrictions published between January 1990 and December 2016. A quality assessment and data extraction were performed by two investigators. The clinical efficacy of and major complications associated with treatment were analysed using a fixed effects model.

KEY FINDINGS

A total of 552 patients in 16 studies were included in this meta-analysis. The clinical success rate in CDT was approximately 100% (95% confidence interval (CI): 99%, 100%), the primary bleeding rate was 0.02% (95% CI: 0%, 0.05%), and mortality during hospitalization was approximately 0% (95% CI: 0%, 0.01%). The mean decrease in pulmonary artery systolic pressure after treatment was -14.9% (95% CI: -19.25%, -10.55%), and the mean post-treatment change in the ratio of the right to the left ventricle (RV/LV) was -0.35% (95% CI: -0.48%, -0.22%).

SIGNIFICANCE

CDT is effective and safe as a treatment for SPE and could be a first-line treatment for SPE under specific conditions.

Catheter-Directed Therapy for Acute Submassive Pulmonary Embolism: Summary of Current Evidence and Protocols

Treatment of acute submassive pulmonary embolism (PE) with thrombolytic therapy remains an area of controversy. For patients who fail or who have contraindications to systemic thrombolysis, catheter-directed therapy (CDT) may be offered depending on the patient's condition and the available institutional resources to perform CDT. Although various CDT techniques and protocols exist, the most studied method is low-dose catheter-directed thrombolytic infusion without mechanical thrombectomy. This article reviews current protocols and data on the use of CDT for acute submassive pulmonary embolism.

Surgical Embolectomy in Acute Massive Pulmonary Embolism

Acute pulmonary embolism is a serious condition and despite diagnostic and therapeutic advances, mortality is still high. Anticoagulation, thrombolytic therapy, catheter embolectomy, and open pulmonary embolectomy are therapeutic options. Surgical embolectomy was considered the management of last resort, but recent studies show the effectiveness of this therapeutic modality. We reviewed our 7-year experience of pulmonary embolectomy in patients with acute massive pulmonary embolism from 1997 to 2004. Eleven patients underwent open embolectomy, 7 (64%) were male, and the mean age was 45.6 years. Pulmonary embolism occurred after major surgery in 5 patients (46%), 2 were diagnosed with malignancy and spinal cord injury, and no risk factors were detected in 4. The diagnosis was made by spiral computed tomography alone in 4 patients, and by angiography in 7. Cardiac arrest occurred in 3 patients preoperatively; 2 of them survived. Open pulmonary embolectomy is the most effective treatment for acute massive pulmonary embolism. Cardiac arrest is the worst prognostic factor. Less aggressive clot evacuation in patients who are diagnosed late appears to be effective in minimizing postoperative hemoptysis.

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.

Fatal massive and recurring pulmonary embolism followed by thrombocytopenia developed after heparin and warfarin treatment in a patient with metastatic breast cancer with an incidental large right atrial thrombus

A thromboembolic complication such as pulmonary embolism in patients who had cancer and mobile thrombi in the heart is a rare but fatal complication. Surgical thromboembolectomy is considered as the classical treatment of choice. In case of inoperable patient, catheter-directed therapy may be an alternative treatment. We report an interesting case of metastatic breast cancer with a large and mobile right atrial thrombus complicated by a massive and subsequently recurring pulmonary embolism, followed by thrombocytopenia developed after heparin and warfarin treatment.

Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients

BACKGROUND

Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period.

METHODS

Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients.

RESULTS

Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018).

CONCLUSIONS

This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.

Successful management of acute massive pulmonary embolism using Angiovac suction catheter technique in a hemodynamically unstable patient

Massive pulmonary embolism with hemodynamic instability is a life-threatening condition requiring immediate treatment. Urgent thrombectomy or thrombolysis is commonly used for the treatment of this condition. However, surgery is associated with high mortality rate and many patients have contraindications to thrombolytic therapy and are at high risk for bleeding. Cather-based intervention has gained increasing popularity particularly in patients with contraindication to thrombolytic therapy or at high risk for surgical thrombectomy. Catheter-based thrombus removal can be achieved by many means such as suction, fragmentation, extraction or rheolytic thrombectomy. We present a case of an elderly lady who suffered from acute massive pulmonary embolism with hemodynamic compromise successfully treated with AngioVac catheter system (AngioDynamics, Albany, NY) with full recovery.

Management of peripheral pulmonary emboli with the use of transvenous catheter-directed thrombolysis and right ventricular assist device

OBJECTIVES

Pulmonary emboli (PE) can result in significant hemodynamic instability that requires urgent intervention; however, the management of peripheral emboli has been controversial.

PATIENTS AND METHODS

We present two patients in whom a right ventricular assist device (RVAD) was used in treating peripheral pulmonary embolism, applying the technique of pulmonary artery catheter-directed thrombolysis after resuscitation with an RVAD.

RESULTS

The clot burden was not suitable for surgical embolectomy due to its peripheral locations. The patients' hemodynamic conditions improved with thrombolytic therapy and gradually were weaned off the RVAD. Follow-up scans showed near resolution of all PE.

CONCLUSION

Catheter-directed thrombolysis with an RVAD as an adjunct should be considered in management of peripheral PE.

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.

Massive and submassive pulmonary embolism: experience with an algorithm for catheter-directed mechanical thrombectomy

BACKGROUND

The role of catheter-directed mechanical thrombectomy (CDMT) for the treatment of massive pulmonary embolism (MPE) and submassive pulmonary embolism (SMPE) is not clearly defined. We report our experience with an algorithm for CDMT as a primary treatment in patients with MPE and SMPE.

METHODS

We retrospectively reviewed our experience in treating MPE and SMPE in consecutive patients over a 2-year period (2008-2010). Patients with computed tomography angiography evidence of saddle, main branch, or ≥2 lobar pulmonary emboli in the setting of hypoxia, tachycardia, echocardiographic right heart strain, and/or cardiogenic shock underwent AngioJet CDMT, with or without adjunctive thrombolytic power-pulse spray. Outcomes, including angiographic success, clinical improvement, complications, and survival to discharge, were evaluated.

RESULTS

Fifteen patients (8 men, 7 women; 14 SMPE, 1 SMPE) with a mean age of 59 years (range: 35-90 years) were treated for heart strain (100%), tachycardia (67%), hypoxia (67%), and cardiogenic shock (7%). Ten patients (67%) also received Alteplase power-pulse spray. Resolution of symptoms and improvement in heart strain were achieved in all patients. There were no in-hospital mortalities. Complications occurred in 3 patients (20%), including 2 patients with acute tubular necrosis and 1 patient with an intraoperative cardiac arrest. Average hospitalization was 9 days (range: 4-26 days). All patients were discharged on full anticoagulation. None required supplemental oxygen at discharge.

CONCLUSION

CDMT as primary treatment of MPE and SMPE has a high rate of technical and clinical success in a high-risk patient population. Experience and strict patient selection criteria may improve therapeutic outcomes.

Massive pulmonary embolism: treatment with the rotarex thrombectomy system

This study was designed to evaluate the efficacy and safety of percutaneous mechanical thrombectomy (PMT) for acute massive pulmonary embolism (PE). Fourteen patients (8 men, 6 women) with a mean age of 55.4 (range, 38-71) years with acute massive PE were initially diagnosed by computed tomography (CT) and confirmed by pulmonary angiography. All patients presented with acute PE symptoms and hemodynamic compromise. Each patient was treated with Straub Rotarex thrombectomy device and five patients received additional thrombolysis. Technique success and clinical improvement were achieved in all patients without major complications. The mean pulmonary artery pressure (PAP) decreased from 37.6 ± 6.6 to 29 ± 6.4 mmHg (P < 0.01) after PMT. Partial arterial pressures of O(2) (PaO(2)) increased from 61.1 ± 9.2 to 88 ± 5.1 mmHg (P < 0.01). The Miller index was 0.67 ± 0.11 and 0.37 ± 0.13 (P < 0.01), respectively, before and after PMT (P < 0.01). Eleven patients had no recurrence of PE on a mean follow-up of 28.3 months, whereas the other three patients were lost to follow-up. The preliminary experience in our series suggests that the Straub Rotarex thrombectomy device, which has been utilized in peripheral arteries, also is useful for the treatment of acute massive 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.

Open pulmonary thromboembolectomy in patients with major pulmonary thromboembolism

PURPOSE

We retrospectively analyzed open pulmonary thromboembolectomy in patients with acute and chronic pulmonary thromboembolism.

MATERIALS AND METHODS

Between August 1990 and May 2005, 12 consecutive patients with acute and chronic pulmonary thromboembolism underwent open pulmonary thromboembolectomy at Yonsei Cardiovascular Center. Their mean age was 47.5 years, and 7 of the patients were female. Among 12 patients, 5 had acute onset, and 7 had chronic disease, and 9 patients were associated with deep venous thrombosis. Extent of pulmonary embolism was massive in 3 patients with hemodynamic instability, and submassive in 8 patients. Preoperative echocardiogram revealed elevated right ventricular pressure in all patients, and 7 patients were in NYHA functional class III or IV. Pulmonary thromboembolectomy was performed in all patients under total circulatory arrest.

RESULTS

There were 2 hospital deaths (16.7%). Among the patients who survived, mean right ventricular pressure was decreased significantly from 64.3 mmHg to 34.0 mmHg with improvement of NYHA functional class.

CONCLUSION

Open pulmonary thromboembolectomy is thought to be an immediate and definitive treatment for massive pulmonary embolism with optimal results. Even though operative mortality is still high, early diagnosis and immediate surgical intervention in highly selective patients may improve the clinical outcome.

Catheter-directed embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis

PURPOSES

The standard medical management for patients in extremis from massive pulmonary embolism (PE) is systemic thrombolysis, but the utility of this treatment relative to catheter-directed intervention (CDI) is unknown. We evaluated the effectiveness of CDI as part of a treatment algorithm for life-threatening PE.

METHODS

A retrospective review was performed on 70 consecutive patients with suspected acute PE over a 10-year period (from 1997 to 2006) who had been referred for pulmonary angiography and/or intervention. The criteria for study inclusion were patients who received CDI due to angiographically confirmed massive PE and hemodynamic shock (shock index, > or = 0.9). CDI involved suction embolectomy and fragmentation with or without catheter thrombolysis.

RESULTS

Twelve patients were treated with CDI. There were seven men and five women (mean age, 56 years; age range, 21 to 80 years). Seven patients (58%) were referred for CDI after failing systemic infusion with 100 mg of tissue plasminogen activator, and five patients (42%) had contraindications to systemic thrombolysis. Catheter-directed fragmentation and embolectomy were performed in all patients (100%). Additionally, catheter-guided thrombolysis was performed in eight patients (67%). Technical success was achieved in 12 of 12 cases (100%). There were no major procedural complications (0%). Significant hemodynamic improvement (shock index, < 0.9) was observed in 10 of 12 cases (83%). The remaining two patients (17%) died secondary to cardiac arrest within 24 h. Ten of 12 patients (83%) survived and remained stable until hospital discharge (mean duration, 20 days; range, 3 to 51 days).

CONCLUSION

In the setting of hemodynamic shock from massive PE, CDI is potentially a life-saving treatment for patients who have not responded to or cannot tolerate systemic thrombolysis.

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.

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.

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.

Management of unsuccessful thrombolysis in acute massive pulmonary embolism

BACKGROUND

The management of patients with acute massive pulmonary embolism (PE) who do not respond to fibrinolytic therapy remains unclear. We aimed to compare rescue surgical embolectomy and repeat thrombolysis in patients who did not respond to thrombolysis.

METHODS

We conducted a prospective single-center registry of PE patients who underwent thrombolytic therapy. Lack of response to thrombolysis within the first 36 h was prospectively defined as both persistent clinical instability and residual echocardiographic right ventricular dysfunction. Patients underwent surgical embolectomy or repeat thrombolysis, at the discretion of the attending physician. The clinical end point was a combined end point including recurrent PE, bleeding complications, or PE-related death, which was defined as death from recurrent PE or cardiogenic shock. Long-term adverse outcomes included death, recurrent thromboembolic events, and congestive heart failure.

RESULTS

From January 1995 to January 2005, 488 PE patients underwent thrombolysis, of whom 40 (8.2%) did not respond to thrombolysis. Fourteen patients were treated by rescue surgical embolectomy, and 26 were treated by repeat thrombolysis. There was no significant difference in baseline characteristics between the two groups. The in-hospital course was uneventful in 11 of the surgically treated patients (79%) and in 8 patients (31%) treated by repeat thrombolysis (p = 0.004). There was a trend for higher mortality in the medical group than in the surgical group (10 vs 1 deaths, respectively; p = 0.07). There were significantly more recurrent PEs (fatal and nonfatal) in the repeat-thrombolysis group (35% vs 0%, respectively; p = 0.015). While no significant difference was observed in number of major bleeding events, all bleeding events in the repeat-thrombolysis group were fatal. The rate of uneventful long-term evolution was the same in the two groups.

CONCLUSION

Rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in patients with massive PE who have not responded to thrombolysis. The transfer of patients who have not responded to thrombolysis to tertiary cardiac surgery centers could be considered as an alternative option.

AngioJet rheolytic thrombectomy versus local intrapulmonary thrombolysis in massive pulmonary embolism: a retrospective data analysis

PURPOSE

To compare the efficacy of full-dose local intrapulmonary thrombolysis (LIT) versus AngioJet rheolytic thrombectomy (ART) in the treatment of massive pulmonary embolism.

METHODS

A retrospective review was conducted of 8 consecutive patients (5 women; mean age 66.0+/-5.9 years, range 56-74) who underwent LIT with high-dose intrapulmonary urokinase (4400 IU/kg over 10 minutes followed by a 2000-IU/kg/h infusion) and a subsequent 6 consecutive patients (4 men; mean age of 59.2+/-17.0 years, range 26-69) who underwent ART plus adjunctive low-dose urokinase infusions (100,000 IU) until hemodynamic recovery was achieved. Pre and postprocedural Miller scores were calculated, and relative Miller score improvement, total urokinase doses, and duration of therapy were compared.

RESULTS

Hemodynamic stability was restored in all 8 LIT patients and in 5 (83%) of the 6 ART patients; 1 (16.7%) patient died during the ART procedure due to recurrent MPE. In the LIT group, the mean Miller score prior to intervention was 17.38+/-2.67, which was reduced to 6.13+/-1.46 after the intervention (p<0.0001) compared to scores of 18.83+/-2.86 and 6.83+/-2.79, respectively, in the ART group (p<0.0001). The mean urokinase dose was 2.07+/-0.44 million IU in the LIT group versus 0.70+/-0.36 million IU in the ART group (p<0.0001). The mean duration of therapy was 11.45+/-2.94 hours in the LIT group versus 3.37+/-1.41 hours in the ART group (p<0.0001). No significant difference in relative Miller score improvement was observed.

CONCLUSION

By accelerating the fragmentation of thrombus, ART plus adjunctive low-dose urokinase seems to be more rapidly effective compared to LIT. ART achieves both rapid cardiovascular relief and reduces the dose of thrombolytic agent necessary in patients with massive pulmonary embolism.

Percutaneous Catheter Thrombectomy Device for Acute Pulmonary Embolism: In Vitro and in Vivo Testing

PURPOSE

To evaluate a percutaneous pulmonary embolism (PE) thrombectomy catheter that aspirates, macerates, and removes thrombus.

MATERIALS AND METHODS

Nine in vitro tests were performed by using porcine thrombi at a PE test station that provides continuous fluid output of 2 L/min at a pressure of 50 mmHg. Macroembolization was defined as embolized particles larger than 1.5 mm in dimension; microembolization was defined as particles that range in size from 0.1 to 1.5 mm. In static in vitro tests, researchers measured plasma-free hemoglobin levels in a 36-year-old man to assess mechanical hemolysis. Investigational review board approval and informed consent were obtained. The Department of Agriculture, Veterinary Bureau, Bern, Switzerland approved in vivo tests. Researchers investigated device effectiveness in 10 pigs that developed cardiogenic shock but survived massive PE after injection of two or three porcine thrombi into the external jugular vein via a surgically implanted 24-F sheath. Pulmonary angiography and hemodynamic measurements, including mean aortic and mean pulmonary artery pressure, heart rate, and mixed venous oxygen saturation, were obtained at baseline, after embolization, and after thrombectomy. Repeated-measures analysis of variance was performed to compare hemodynamic measurements at baseline, after embolization, and after thrombectomy. Cardiovascular structures were examined at necropsy for rupture, perforation, dissection, or hemorrhage.

RESULTS

During a mean aspiration time of 69 seconds +/- 19, thrombi were completely extracted from 14-mm test tubes, with an aspirated fluid volume of 201 mL +/- 64. Although no macroembolization was observed, microembolization was quantified at 1.9 g +/- 1.3. Catheter aspiration was not associated with an increase in plasma-free hemoglobin. In 10 animals, aortic pressure increased from 52 mmHg +/- 24 before thrombectomy to 90 mmHg +/- 32 after thrombectomy, mixed venous oxygen saturation increased from 48% +/- 19% to 61% +/- 12%, pulmonary artery pressure decreased from 33 mmHg +/- 9 to 22 mmHg +/- 4, and heart rate decreased from 162 beats per minute +/- 24 to 114 beats per minute +/- 14. We did not observe macro- or microscopic damage to treated or untreated cardiovascular structures.

CONCLUSION

The PE thrombectomy device was highly effective, facilitating rapid reversal of cardiogenic shock without device-related complications.

Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach

OBJECTIVES

This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate.

METHODS

Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24-86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest.

RESULTS

There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3-75 days). Median follow-up was 27 months (range, 2-50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years' follow-up was 86% and 83%, respectively.

CONCLUSION

An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.

Pulmonary Embolectomy for Acute Massive Pulmonary Embolism

BACKGROUND

Acute massive pulmonary embolism usually results in death if not diagnosed early and treated aggressively. Thrombolytic therapy and catheter embolectomy are increasingly used as definitive management. Emergent open embolectomy is often reserved as a last resort when less invasive methods have failed or the patient is in cardiopulmonary arrest.

METHODS

We reviewed our experience with early open pulmonary embolectomy in patients with acute massive pulmonary embolism from January 1998 to February 2004.

RESULTS

Eleven patients underwent early pulmonary embolectomy. Five (45%) patients were men, and the average age was 48 years. In 4 (36%) patients, a massive pulmonary embolism occurred after a surgical procedure or trauma. The remaining 7 patients had chronic medical diseases. The diagnosis was established primarily by clinical findings along with spiral computerized tomography or transesophageal echocardiography. Eight (73%) patients survived and were discharged from the hospital. The 3 patients who died suffered cardiac arrest preoperatively and were taken to the operating room with cardiopulmonary resuscitation in progress. Only 1 patient survived after preoperative cardiac arrest.

CONCLUSIONS

Early open pulmonary embolectomy using cardiopulmonary bypass is an effective form of treatment for acute massive pulmonary embolism with excellent long-term results. Preoperative cardiac arrest is associated with a high mortality. Spiral computerized tomography and transesophageal echocardiography are important diagnostic tools.

Right Ventricular Enlargement on Chest Computed Tomography

Background— In patients with acute pulmonary embolism (PE), rapid and accurate risk assessment is paramount in selecting the appropriate treatment strategy. Right ventricular (RV) enlargement on chest CT has previously been shown to correlate with an unstable hospital course, but its role as a predictor of death is unknown.

Methods and Results— We evaluated 431 consecutive patients (mean age, 59±16 years; 55% women) with acute PE confirmed by multidetector-row chest CT. With the use of multiplanar reformats of axial CT data, CT 4-chamber (4-CH) views were reconstructed and right and left ventricular dimensions (RV D , LV D ) were measured. RV enlargement, defined as RV D /LV D >0.9, was present in 276 (64.0%; 95% CI, 59.5% to 68.6%) patients. Thirty-day mortality rate was 15.6% (95% CI, 11.3% to 19.9%) in patients with and 7.7% (95% CI, 3.5% to 12.0%) without RV enlargement (log rank, P =0.018). The hazard ratio of RV D /LV D >0.9 for predicting 30-day death was 3.36 (95% CI, 1.13 to 9.97; P =0.029). On multivariable analysis, RV enlargement predicted 30-day death (hazard ratio, 5.17; 95% CI, 1.63 to 16.35; P =0.005) after adjusting for pneumonia (hazard ratio, 2.95; 95% CI, 1.19 to 3.83; P =0.002), cancer (hazard ratio, 2.13; 95% CI, 1.19 to 3.83; P =0.011), chronic lung disease (hazard ratio, 2.00; 95% CI, 1.04 to 3.86; P =0.039), and age (hazard ratio, 1.03; 95% CI, 1.01 to 1.05; P =0.005).

Conclusions— In patients with acute PE, RV enlargement on reconstructed CT 4-CH view helps predict early death.

Open pulmonary embolectomy for treatment of major pulmonary embolism

BACKGROUND

Inadequate data exist regarding the management of acute major pulmonary embolism. Various modalities that are used, including thrombolytics and embolectomy, have not been shown to conclusively improve mortality when compared to heparin. In the past, open pulmonary embolectomy was reserved for patients with severe hemodynamic instability because of its high mortality rate. Our objective was to analyze our experience with early embolectomy as an alternative for the treatment of major pulmonary embolism.

METHODS

A retrospective review of charts of all patients undergoing pulmonary embolectomy at our institution over the last two years was performed. Patients were followed until their discharge from hospital.

RESULTS

There were 13 patients (7 women and 6 men). Four had massive and 9 had submassive pulmonary embolism. There was one mortality. Postoperative echocardiography showed no evidence of pulmonary hypertension in 7.

CONCLUSIONS

Open pulmonary embolectomy can be performed in patients with major pulmonary embolism with minimal mortality and morbidity. It may prevent the development of chronic thromboembolic pulmonary hypertension and should be a part of the algorithm in the treatment of major pulmonary embolism.

The vasculopathic patient: uncommon surgical emergencies

Recognition of the patient who has an emergent vascular disorder and the early initiation of simple management steps in the ED can significantly impact patient outcome. The vasculopathic patient presents with significant comorbid conditions and a small window of opportunity to alter the prognosis favorably. The critical role of the EP lies in prompt use of this opportunity and appropriate direction of further care.

Usefulness of a 6 Fr Right Judkins Catheter for Mechanically Extracting a Massive Intracoronary Thrombus From an Ectasic Right Coronary Artery: A report on two different cases of thrombectomy

In order to bail out the slow-flow phenomenon (slow flow) created by a massive thrombus in an ectasic right coronary artery, a thrombus was mechanically extracted with a 6 Fr right Judkins (JR) catheter, which proved to be more useful than a usual thrombectomy using a Rescue PT system catheter (Rescue). In case 1, the Rescue was used in combination with thrombolysis but failed to alleviate the slow flow that was implicated in a large infarction. On the other hand, in case 2, aggressive thrombectomy with a 6 Fr JR catheter with an 8 Fr Amplatz guiding catheter successfully extracted the massive intracoronary thrombus, restoring good coronary flow. Therefore, mechanical extraction with a 6 Fr JR catheter is safe and useful in cases of massive thrombus when diffuse coronary artery ectasia complicates an acute myocardial infarction. In addition, this method should be applicable to cases of acute coronary syndrome with massive thrombus.

Diagnosis and treatment of venous thromboembolism

The diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) has been improved and simplified over the past decade thanks to advances in noninvasive and readily accessible technology. With high degrees of sensitivity and specificity, venous ultrasonography is favored as the initial investigation for DVT. To diagnose PE, most clinicians rely on diagnostic algorithms that combine clinical assessment, noninvasive lung studies, and, if necessary, venous ultrasonography of the legs and D-dimer testing. Substantial progress has also occurred in the treatment of acute venous thromboembolism with the introduction of low-molecular-weight heparins. This class of antithrombotic agents has changed initial therapy from an inpatient, intravenous regimen that required laborious monitoring to an outpatient practice using weight-adjusted doses of once-daily subcutaneous injections. In addition, several new anticoagulants with theoretical advantages over existing agents have entered phase III studies. Aspects of thrombosis treatment that remain controversial include vena caval interruption and the indications for thrombolysis and surgical thromboembolectomy.

Acute pulmonary embolectomy: a contemporary approach

BACKGROUND

Acute pulmonary embolism confers a high mortality rate despite advances in diagnosis and therapy. Thrombolysis is often effective but has a high frequency of major bleeding complications, especially intracranial hemorrhage. Therefore, we liberalized our criteria for acute pulmonary embolectomy and considered operating on patients with anatomically extensive pulmonary embolism and concomitant moderate to severe right ventricular dysfunction despite preserved systemic arterial pressure.

METHODS AND RESULTS

We report 29 (17 men and 12 women) consecutive patients who underwent embolectomy from October 1999 through October 2001. Twenty-six patients (89%) survived surgery and were alive more than 1 month postoperatively. Median follow-up is 10 months.

CONCLUSION

The high survival rate of 89% can be attributed to improved surgical technique, rapid diagnosis and triage, and careful patient selection. We hope that other tertiary centers will evaluate pulmonary embolism patients with an algorithm that includes surgical embolectomy as one of several therapeutic options. Our contemporary approach to pulmonary embolectomy no longer confines this operation to a treatment of last resort reserved for clinically desperate circumstances.

A contemporary approach to thrombolytic therapy for pulmonary embolism

Successfully utilized contemporary pulmonary embolism thrombolysis reverses right heart failure rapidly and safely. This therapeutic approach may lower mortality from pulmonary embolism and reduce morbidity from chronic pulmonary hypertension. Unlike myocardial infarction thrombolysis, a 2-week 'time window' is available, during which treatment can be initiated. A high concentration of the thrombolytic agent is administered in a brief infusion lasting several hours. No special laboratory testing is needed. Currently, the only contemporary thrombolytic regimen for pulmonary embolism that is approved by the Food and Drug Administration is tissue plasminogen activator, in a dose of 100 mg/2 h. New thrombolytic agents under development for pulmonary embolism include reteplase, saruplase, and recombinant staphylokinase. Future clinical trials will require multicenter collaboration and will focus on relevant endpoints such as the reduction of mortality and recurrent venous thromboembolism.

Interventional therapy for pulmonary embolism

Venous thromboembolism is a common cause of death. Acute massive pulmonary embolism (PE) is life-threatening and may require vigorous more invasive treatment. Several risk factors are related to increased incidence of massive PE. Anticoagulation is the most traditional treatment for PE but may not suffice in cases of massive PE. Systemic thrombolytic therapy, catheter-directed thrombolysis, percutaneous embolectomy, and more recently, percutaneous thrombus fragmentation techniques with a multitude of devices are now available to treat the most severe cases of massive PE. Successful treatment of PE includes implementation of a treatment protocol and the use of associated techniques and devices.

Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter

OBJECTIVES

This study was designed to assess the feasibility, efficacy and safety of mechanical fragmentation of pulmonary emboli using a new rotational pigtail catheter system.

BACKGROUND

Acute massive pulmonary embolism associated with right ventricular dysfunction is frequently lethal, despite high-dose thrombolytic therapy. Adjunctive catheter fragmentation may prevent a fatal outcome.

METHODS

In 20 patients (age 58.9+/-10.5 years) with severe hemodynamic impairment, massive pulmonary emboli were fragmented by mechanical action of the rotating pigtail. Fifteen patients received thrombolysis after embolus fragmentation or no thrombolysis at all (noninterference group).

RESULTS

Prefragmentation pulmonary arterial occlusion was 68.6 +/- 11.3% for both lungs. Pulmonary placement and navigation of the fragmentation catheter was easy and rapid. Fragmentation time was 17+/-8 min. The noninterference group showed a decrease pre- to postfragmentation of shock index from 1.28+/-0.53 to 0.95+/-0.38 (p = 0.011), mean pulmonary artery pressure from 31+/-5.7 to 28+/-7.5 mm Hg (p = 0.02) and a recanalization by fragmentation of 32.9+/-11.8% (mean angiographic score per treated lung from 7.4 to 5.0). Overall mortality was 20%.

CONCLUSIONS

Fragmentation by pigtail rotation catheter provided for a rapid and safe improvement of the hemodynamic situation and an average recanalization of about one-third of the pulmonary embolic occlusion. The method appears useful especially in high-risk patients threatened by right ventricular failure, to accelerate thrombolysis, and as a minimal-invasive alternative to surgical embolectomy.

Acute massive pulmonary embolism in a Jehovah's witness: successful treatment with catheter thrombectomy

A 71-year-old woman presented with an acute, massive pulmonary embolism. As a Jehovah's Witness, she was not willing to accept thrombolysis because of the potential risk of bleeding requiring blood transfusion. The patient was successfully treated with catheter thrombectomy, using rheolytic and fragmentation devices. (CHEST 2000; 117:594-597)