Pulmonary Vascular Disease |

A Case of Acute Pulmonary Embolism Treated With Ultrasound-Assisted Catheter-Directed Thrombolysis FREE TO VIEW

Michael Colancecco, DO; Rajesh Zacharias, MBBS; Scott Kopec, MD; Gisela Banauch, MD
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University of Massachusetts, Worcester, MA

Chest. 2014;146(4_MeetingAbstracts):868A. doi:10.1378/chest.1994496
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SESSION TITLE: Pulmonary Vascular Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Ultrasound-assisted catheter-directed thrombolysis (USAT) is a promising treatment for acute pulmonary embolism (PE). We present a case of acute PE in which this technology was successfully utilized.

CASE PRESENTATION: A 65 year old man presented with dyspnea following tibial fracture repair. Examination revealed a room air oxygen saturation of 77%, with normal hemodynamics. Breath sounds were normal bilaterally but there was right sided lower extremity edema. Laboratory studies were unremarkable aside from a troponin I of 0.62. A computer tomography scan with angiography demonstrated large bilateral pulmonary emboli originating within both main pulmonary arteries. A two-dimensional echocardiogram demonstrated new right ventricular strain. The patient was admitted to the intensive care unit and treated with unfractionated heparin and non invasive positive pressure ventilation (NIPPV) which he required for adequate oxygenation. Interventional radiology was consulted and the patient was treated with USAT for 24 hours without complication. A repeat pulmonary angiogram demonstrated significant reduction of clot burden and corresponded with clinical improvement in oxygenation and eventual discharge on room air.

DISCUSSION: Patients with acute pulmonary embolism (PE) can be stratified into low, intermediate and high risk groups for short term mortality to help dictate management. An area of controversy involves the best therapeutic option for patients with intermediate risk acute PE. USAT is a novel treatment option in conjunction with anticoagulation for the treatment of acute PE. This modality allows for local delivery of TPA and endovascular ultrasound directly to the site of thrombus. An initial randomized controlled trial has shown this treatment to be effective in reducing right ventricular to left ventricular ratio at 24 hours without increased risk of bleeding. While improvement in mortality or clinical endpoints at ninety days have yet to be demonstrated, our case does provide an encouraging example of the potential benefit of this therapy.

CONCLUSIONS: Ultrasound-assisted catheter-directed thrombolysis provides an additional treatment option for patients with intermediate risk acute PE, particularly in the setting of refractory hypoxemia or in patients with contraindications to systemic thrombolysis.

Reference #1: Kucher N, Boekstegers P, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 2014; 129:479.

DISCLOSURE: The following authors have nothing to disclose: Michael Colancecco, Rajesh Zacharias, Scott Kopec, Gisela Banauch

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