PURPOSE: 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 (embolectomy, fragmentation, ± thrombolysis) used as part of a treatment algorithm for life-threatening pulmonary embolism.
METHODS: A retrospective review was performed on 70 consecutive patients with suspected acute PE over a 10-year period (1997-2006) referred to our department for pulmonary angiography and/or possible intervention. Criteria for study inclusion were patients who received emergency CDI due to angiographically confirmed massive pulmonary embolism, with involvement of the central pulmonary arteries, and severe hemodynamic impairment defined as a shock index (heart rate/systolic blood pressure) > 1. CDI involved suction embolectomy and fragmentation (rotating pigtail) with or without catheter thrombolysis.
RESULTS: Twelve patients were treated with catheter-directed intervention. There were 7 men and 5 women with mean age of 56 years (range 21-80). Seven patients (58%) were referred for CDI after failing systemic thrombolytic infusion and 5 patients (42%) had contraindications to systemic thrombolysis. Catheter-directed fragmentation and embolectomy were emergently performed in all patients (100%). Additionally, catheter-guided thrombolyis was performed in eight patients (67%). Technical success was achieved in all cases (100%) and there were no complications (0%). Post-treatment angiography showed improvement in pulmonary perfusion in 11/12 patients (92%). Hemodynamic improvement (shock index < 1) was observed in all patients (100%) following intervention. Mean O2 saturation improved from 58% before treatment to 96% following CDI (p<0.01). Two patients (17%) died secondary to cardiac arrest within one day of treatment. Ten out of twelve (83%) patients survived and remained stable until discharge (mean stay: 20 d, range: 3-51 d).
CONCLUSION: Catheter-directed intervention is a life-saving treatment for patients in extremis from massive acute PE.
CLINICAL IMPLICATIONS: In the setting of hemodynamic shock from massive PE, CDI may be performed with or without local thrombolysis and is useful in patients who have failed or cannot tolerate systemic thrombolysis.
DISCLOSURE: William Kuo, No Financial Disclosure Information; Product/procedure/technique that is considered research and is NOT yet approved for any purpose. The use of sheaths and catheters for pulmonary embolectomy and fragmentation may be considered as off-label use of these devices. Intrapulmonary injection of thrombolytic drugs is considered off-label use.