To assess the impact of mechanical thrombectomy followed by local intrapulmonary thrombolysis on long term outcome of patients presenting with acute massive pulmonary embolism.
: Prospectively consecutive 30 patients (25M, 5F) with mean age 47 ± 12 years presenting with clinical diagnosis of pulmonary embolism and shock index (heart rate/systolic blood pressure) > 1 underwent emergent pulmonary angiography. Miller index ,pulmonary and systemic hemodynamics were recorded.. After ensuring flow across pulmonary artery with mechanical breakdown of embolus by 5F pig tail catheter; bolus dose of urokinase (4400 IU/kg ) over 10 minutes followed by 4400 IU/kg/hr for 16–24 hours was given in pulmonary artery thrombus. Pulmonary artery pressures and Shock index were recorded hourly. Repeat pulmonary angiogram was done 24 hours post procedure. Subsequently patients were treated with oral anticoagulants. After discharge transthoracic echocardiography (TTE) was done at mean follow-up of 18 months (range 12–30).
Pigtail rotational mechanical thrombectomy restored antegrade flow in all patients. Shock index decreased gradually to < 1 within 8 hours. The average heart rate, mean pulmonary artery pressure, Miller index, Shock index decreased significantly from 128 ± 19bpm, 41 ± 5 mmHg, 18 ± 5, 1.3 ± 0.3 to 95 ± 14 bpm, 24 ± 5 mmHg, 5 ± 2, 0.8 ± 0.2 respectively after 24 hrs of urokinase infusion) (P < 0.05). Inhospital mortality was 6.6% (2/30 pts due to persistent shock, metabolic acidocis and renal failure) with minor bleeding complications in 3 patients. At a mean followup of 18 months TTE showed normal pulmonary artery pressures, right ventricular size and function in 27/28 surviving patients with no recurrence of pulmonary embolism.
Mechanical thrombectomy followed by local intrapulmonary thrombolysis results in rapid resolution of shock and restoration of pulmonary arterial perfusion with low in hospital morbidity and mortality. It also provides excellent long term outcomes.
This minimally invasive procedure can score over systemic thrombolysis in management of acute massive pulmonary embolism.
Bishav Mohan, No Financial Disclosure Information; No Product/Research Disclosure Information