Catheter-Based Therapies for Massive Pulmonary Embolism

doi:10.1016/j.pcad.2010.01.002

Progress in Cardiovascular Diseases

Volume 52, Issue 5, March–April 2010, Pages 429-437

https://doi.org/10.1016/j.pcad.2010.01.002 Get rights and content

Abstract

Massive pulmonary embolism carries a high mortality rate as a result of right ventricular failure. In addition to anticoagulation, systemic thrombolysis is the standard first line of therapy for patients with life-threatening massive pulmonary embolism. Surgical embolectomy is often considered in patients with contraindications to receiving systemic thrombolysis or when thrombolysis has failed. Surgical embolectomy is not without inherent risk and limitations.Although there is a paucity of large clinical trials, available data suggests catheter-based treatment of massive pulmonary embolism restores hemodynamic stability and thus is an alternative to surgical therapy.

Section snippets

Surgical embolectomy

Surgical embolectomy offers the advantage of complete removal of proximal thrombus and immediate relief of RV strain (Fig 1). Surgical embolectomy was first proposed by Trendelenburg¹⁰ in 1908 and successfully performed by Kirschner¹¹ in 1924. After decades of clinical failures, it was reintroduced in the 1960s12, 13 but continued to be associated with mortality rates exceeding 30%.¹⁴ Recently, better patient selection and advances in surgical and anesthesiology techniques led to improved

Greenfield embolectomy catheter

The original device was developed in 1960s and consisted of a metal suction cup attached to a straight catheter.6, 19 It remains today as the only device ever approved by the FDA for percutaneous pulmonary embolectomy. The catheter was introduced through a surgical cut-down in the femoral or jugular vein and a large 24F introducer sheath. The catheter was advanced into the PA and suction applied to the cup through a syringe. The experience of Greenfield et al²⁰ in 46 patients with massive PE

Complications of catheter-based therapies

Many complications of percutaneous interventions are shared across the devices. Injury to the PA and its branches can result in catastrophic complications, such as rupture of the PA,⁴⁸ pericardial tamponade, and life-threatening hemoptysis. Such complications are fortunately rare and can be avoided by avoiding smaller subsegmental branches. Major bleeding complications can be as low as 2.4% in patients who do not receive concomitant systemic thrombolytics.⁷ Worsening of hemodynamic parameters

Conclusions

Catheter-based therapy for massive PE can be a lifesaving therapy. There are no large-scale studies examining this treatment modality, but available data suggest that hemodynamic stability can be restored in 86.5% of patients. In the absence of systemic thrombolysis, the rate of major and minor periprocedural complications can be as low as 10%.⁷ Our current experience comes mostly from single-center, retrospective series and selected patients, but high mortality and morbidity associated with

Statement of Conflict of Interest

All authors declare that there are no conflicts of interest.

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Pulmonary Embolism in Children
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Acute Pulmonary Embolism: with an Emphasis on an Interventional Approach
2016, Journal of the American College of Cardiology
Compared with recent advances in treatment of serious cardiovascular diseases, such as myocardial infarction and stroke, the treatment and outcome of acute pulmonary embolism (PE) have remained relatively unchanged over the last few decades. This has prompted several experts to call for the formation of multidisciplinary PE response teams with a more proactive approach to the treatment of PE. In the current document, we discuss the formation of such teams and describe the available treatment options beyond anticoagulation, with a focus on the interventional approach. Acknowledging the paucity of data to support widespread adoption of such techniques, we call for the collection of outcomes data in multicenter registries and support for randomized trials to evaluate interventional treatments in patients with high-risk PE.
Catheter-directed thrombolysis for severe pulmonary embolism in pediatric patients
2014, Annals of Vascular Surgery
Catheter-directed thrombolytic (CDT) therapies for severe pulmonary embolism (PE) have been shown to be effective and safe when compared with systemic thrombolysis in adults. Pediatric studies assessing efficacy and safety of CDT for PE are lacking. Hence, our aim was to review CDT as a therapy for pediatric PE.
We retrospectively reviewed charts of patients aged <18 years, who underwent CDT for main or major branch pulmonary artery occlusion associated with hypotension or right ventricular dysfunction secondary to PE during a 3-year period, in our tertiary care academic Pediatric Intensive Care Unit.
Six CDT interventions were performed on 5 patients with PE (median age: 16.5 years). All patients presented with chest pain and dyspnea. The predisposing factors for thrombogenesis differed in all patients, and all had multiple risk factors. Five of six procedures (83%) were accompanied by ultrasound agitation with EKOS endowave infusion system (ultrasound-accelerated CDT [UCDT]), whereas 1 had CDT without ultrasound agitation. Complete resolution of PE occurred in 4 instances (67%) at 24 hr, whereas in 2 cases (33%), there was partial resolution. One patient with complete resolution underwent another successful UCDT after 4 months for recurrence. Clinical parameters (heart rate, respiratory rate, blood pressure, and oxygen saturations) and echocardiographic findings improved after treatment in all the patients. Median duration of hospital stay was 9 days with no mortality and treatment-related complications. All patients were discharged with long-term anticoagulation.
Our case series is the first that describes CDT/UCDT as an effective and safe therapy for pediatric patients with severe PE. CDT is known to accelerate fibrinolysis via focused delivery of thrombolytic agent to the thrombus site. For carefully selected patients, CDT/UCDT provides a useful treatment option for severe PE irrespective of the etiology, predisposing conditions, and associated comorbidities.
Management of right heart failure in the critically ill
2014, Critical Care Clinics
Citation Excerpt :
Postoperative RVF also is well-described as a complication of cardiac surgery, including cardiac transplantation and left ventricular assist device (LVAD) implantation, and carries a similar mortality rate of nearly 40%.17–20 Of patients presenting with PE, 30% to 50% have “RV strain” either by elevated levels of biomarkers or echocardiographic evidence of RV dysfunction,21 and 4.5% of patients with PE meet criteria for “massive PE,” defined as systemic hypotension, cardiac arrest, syncope, or a decrease in systolic blood pressure by greater than 40 mm Hg for at least 15 minutes. Massive PE is associated with 90-day mortality rates of up to 50%.21
Impact of catheter fragmentation followed by local intrapulmonary thrombolysis in acute high risk pulmonary embolism as primary therapy
2014, Indian Heart Journal
Pulmonary embolism (PE) with more than 50% compromise of pulmonary circulation results significant right ventricular (RV) afterload leading to progressive RV failure, systemic hypotension and shock. Prompt restoration of thrombolysis, surgical embolectomy, or percutaneous mechanical thrombectomy (PMT) prevents progressive hemodynamic decline. We report our single center experience in high risk PE patients treated with standard pigtail catheter mechanical fragmentation followed by intrapulmonary thrombolysis as a primary therapy.
50 consecutive patients with diagnosis of high risk PE defined as having shock index >1 with angiographic evidence of >50% pulmonary arterial occlusion are included in the present study. All patients underwent emergent cardiac catheterization. After ensuring flow across pulmonary artery with mechanical breakdown of embolus by rotating 5F pigtail catheter; bolus dose of urokinase (4400 IU/kg) followed by infusion for 24 h was given in the thrombus. Hemodynamic parameters were recorded and follow up pulmonary angiogram was done. Clinical and echo follow up was done for one year.
Pigtail rotational mechanical thrombectomy restored antegrade flow in all patients. The mean pulmonary artery pressure, Miller score, Shock index decreased significantly from 41 ± 8 mmHg, 20 ± 5, 1.32 ± 0.3 to 24.52 ± 6.89, 5.35 ± 2.16, 0.79 ± 0.21 respectively (p < 0.0001). In-hospital major complications were seen in 4 patients. There was a statistically significant reduction of PA pressures from 62 ± 11 mmHg to 23±6 mmHg on follow up.
Rapid reperfusion of pulmonary arteries with mechanical fragmentation by pigtail catheter followed by intrapulmonary thrombolysis results in excellent immediate and intermediate term outcomes in patients presenting with high risk pulmonary embolism.

View all citing articles on Scopus

: Statement of Conflict of Interest: see page 436.

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Catheter-Based Therapies for Massive Pulmonary Embolism

Abstract

Section snippets

Surgical embolectomy

Greenfield embolectomy catheter

Complications of catheter-based therapies

Conclusions

Statement of Conflict of Interest

Am J Med

J Am Coll Cardiol

J Surg Res

J Vasc Interv Radiol

Am J Cardiol

Chest

Chest

Lancet

J Am Coll Cardiol

Am J Cardiol

Chest

J Vasc Interv Radiol

Clin Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Chest

Am J Cardiol

J Vasc Interv Radiol

Ultrasound Med Biol

J Vasc Interv Radiol

Chest

Low-molecular-weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism: a meta-analysis of randomized, controlled trials

Ann Intern Med

Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review

Eur Heart J

Massive pulmonary embolism

Circulation

Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction

Circulation

Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism

N Engl J Med

Uber die Operative Behandlung der Embolie der Lungen Arterie

Arch Klin Chir

Ein durch die Trendelenburgsche Operation Geheilter Fall von Embolie der Art. Pulmonalis

Arch Klin Chir