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Paper Presented to the Peripheral Vascular Surgery Society - 21st Annual Winter Meeting| Volume 26, ISSUE 1, P18-24, January 2012

Massive and Submassive Pulmonary Embolism: Experience With an Algorithm for Catheter-Directed Mechanical Thrombectomy

Published:August 31, 2011DOI:https://doi.org/10.1016/j.avsg.2011.05.026

      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.
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      References

        • Anderson Jr., F.A.
        • Wheeler H.B.
        Physician practices in the management of venous thromboembolism: a community-wide survey.
        J Vasc Surg. 1992; 16: 707-714
        • Heit J.A.
        • Cohen A.T.
        • Anderson F.A.
        Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboembolism (VTE) events in the U.S..
        Blood. 2005; 106: 267a
        • Goldhaber S.Z.
        • Visani L.
        • De Rosa M.
        Acute Pulmonary Embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER).
        Lancet. 1999; 353: 1386-1389
        • Eidt-Lidt G.
        • Gaspar J.
        • Sandoval J.
        • et al.
        Combined clot fragmentation and aspiration in patients with acute pulmonary embolism.
        Chest. 2008; 134: 54-60
        • Silverstein M.D.
        • Heit J.A.
        • Mohr D.N.
        • et al.
        Trends in incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study.
        Arch Int Med. 1998; 158: 585-593
        • Agnelli G.
        • Becattini C.
        Acute Pulmonary Embolism.
        New Engl J Med. 2010; 363: 266-274
        • Piazza G.
        • Goldhaber S.Z.
        Current concepts: chronic thromboembolic pulmonary hypertension.
        New Engl J Med. 2011; 364: 351-360
        • Kearon C.
        • Kahn S.R.
        • Agnelli G.
        • et al.
        Antithrombotic therapy for venous thromboembolic disease: American college of Chest Physicians Evidence-based Clinical Practice Guidelines 8th ed.
        Chest. 2008; 133 (454S-545S. Erratum in Chest 2008;134:892)
        • Moussa I.D.
        Percutaneous mechanical thrombectomy in patients with submassive pulmonary embolism: an underutilized and understudied tool!.
        Catheter Cardiovasc Interv. 2011; 77: 148-149
        • Kuo W.T.
        • Gould M.K.
        • Louie J.D.
        • et al.
        Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques.
        J Vasc Interv Radiol. 2009; 20: 1431-1440
        • Torbicki A.
        • Perrier A.
        • Konstantinides S.
        • et al.
        Guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC).
        Eur Heart J. 2008; 29: 2276-2315
        • Jimenez D.
        • Uresandi F.
        • Remedios O.
        • et al.
        Troponin-based risk stratification of patients with acute normotensive pulmonary embolism.
        Chest. 2009; 136: 974-982
        • Goldhaber S.Z.
        Echocardiography in the management of pulmonary embolism.
        Ann Intern Med. 2002; 136: 691-700
        • Jardin F.
        • Dubourg O.
        • Bourdarias J.P.
        Echocardiographic pattern of acute cor pulmonale.
        Chest. 1997; 111: 209-217
        • Goldhaber S.Z.
        Integration of catheter thrombectomy into our armamentarium to treat pulmonary embolism.
        Chest. 1998; 114: 1237-1238
        • Kucher N.
        • Goldhaber S.Z.
        Management of massive pulmonary embolism.
        Circulation. 2005; 112: e28-e32
        • Uflacker R.
        Interventional therapy for pulmonary embolism.
        J Vasc Interv Radiol. 2001; 12: 147-164
        • Lindner D.J.
        • Edwards J.M.
        • Phyinney E.S.
        • et al.
        Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis.
        J Vasc Surg. 1986; 4: 436-442
        • Pengo V.
        • Lensing A.W.
        • Prins M.H.
        • et al.
        Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism.
        N Engl J Med. 2004; 350: 2257-2264
        • Comerota A.J.
        • Throm R.C.
        • Mathias S.D.
        • Haughton S.
        • Mewissen M.
        Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life.
        J Vasc Surg. 2000; 32: 130-137
        • Lin P.H.
        • Chen H.
        • Bechara C.F.
        • et al.
        Endovascular interventions for acute pulmonary embolism.
        Perspect Vasc Surg Endovasc Ther. 2010; 22: 171-182
        • Wan S.
        • Quinalan D.J.
        • Agnelli G.
        • Eikelboom J.W.
        Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials.
        Circulation. 2004; 110: 744-749
        • Dong B.
        • Jirong Y.
        • Liu G.
        • et al.
        Thrombolytic therapy for pulmonary embolism.
        Cochrane Database Syst Rev. 2006; 19: CD004437
        • Dwarka S.A.
        • Schwartz S.H.
        • Smyth
        • et al.
        Bradyarrhythmias during use of the AngioJet system.
        J Vasc Interv Radiol. 2006; 17: 1693-1695
        • Karnabatidis D.
        • Katsanos K.
        • Kagadis G.C.
        • et al.
        Re: bradyarrhythmias during use of the angiojet system.
        J Vasc Interv Radiol. 2007; 18 (Author reply: 937-938): 937
        • Kumar N.
        • Janjigian Y.
        • Schwartz D.R.
        Paradoxical worsening of shock after the use of a percutaneous mechanical thrombecotmy device in a postpartum patient with a massive pulmonary embolism.
        Chest. 2007; 132: 677-679
        • Jeyabalan G.
        • Saba S.
        • Baril T.
        • et al.
        Bradyarrhytmias during rheolytic pharmacomechanical thrombecotmy for deep vein thrombosis.
        J Endovasc Ther. 2010; 17: 416-422
        • Lee M.S.
        • Makkar R.R.
        • Singh V.
        • et al.
        Pre-procedural administration of aminophylline does not prevent AngioJet rheolytic thrombectomy-induced bradyarrythmias.
        J Invasive Cardiol. 2005; 17: 19-22