Massive pulmonary embolism is a risk for cardiac death from right heart failure and survival depends on rapid re-canalization. Traditionally this is achieved with thrombolytics but in severe cases even lytic therapy may fail. In these cases mechanical fragmentation with percutaneous catheter treatment is an option.
86-year-old male smoker with past medical history of deep vein thrombosis, pulmonary embolism, oral cavity CA admitted with syncope. In the emergency room his BP was 82/40mmhg, pulse of 80/m and a pulse ox of 80%. He was treated with intravenous fluids and oxygen. Initial exam showed left neck lymph-adenopathy. Chest was clear bilaterally. S1 and S2 were normal and there was no peripheral edema. Chest X ray was without any acute process. EKG with RBBB and first-degree heart block. D-dimers were > 500.Lower extremity ultrasound showed right superficial femoral, popliteal, posterior tibial and left popliteal vein DVT. A VQ scan was requested but the patient became severely hypotensive and dyspneic resulting in intubation. Pulmonary angiogram showed occluded right pulmonary trunk. The RAP was 21, PAP 65-70/25, PCWP of 17. The patient was treated with mechanical fragmentation of the clot with a pigtail catheter, followed by TPA and I/V heparin. A repeat pulmonary angiogram showed near normal right pulmonary trunk with a PAP of 40 mmhg.DISCUSSION: Patients with massive pulmonary embolism frequently have acute right heart failure. If untreated the out come is frequently fatal. Thrombolytics is the gold standard for treating pulmonary embolism. In severe cases thrombolytics may fail to prevent fatal outcome. Survival depends upon rapid recanalization. The pigtail catheter allows easy manipulation into and within the pulmonary artery. Its tip avoids perforation of the pulmonary artery. Rapid recanalization can be safely achieved with mechanical fragmentation of the clot with the pigtail catheter. Moreover the increased total surface area of the fragments may accelerate the efficacy of the lytics. The average procedure time is 45 minutes and an average fragmentation time of 15 minutes. This recanalization rate achieved by the pigtail compares well with the results of lytics. Recently newer especially designed rotational pigtail catheters have been used with improved success.CONCLUSIONS: Mechanical fragmentation of the thrombus in massive pulmonary embolism with a pigtail catheter is a safe and rapid method to recanalize the pulmonary vasculature and improve the hemodynamics. It is a synergistic adjunct to lytics and an alternative to surgical embolectomy.
K.I. Hamirani, None.