Medical College of Georgia at Augusta University, Augusta, GA
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Systemic tPA is the mainstay therapy for massive or sub-massive pulmonary embolism to accelerate lysis of thrombi; however, catheter directed techniques (CDT) can also be employed in patients who are in severely critical condition or have significant bleeding risk.
CASE PRESENTATION: A 41-year-old male arrived at the ER after a motorcycle collision with ejection. Upon arrival, patient was hemodynamically unstable due to a large retroperitoneal hematoma- ligation and right nephrectomy were performed. On the third hospital day, patient’s systolic blood pressure and oxygen saturation dropped to 60 mmHg and 80%, respectively. CTA showed right upper lobe segmental and multiple subsegmental pulmonary emboli with no obvious DVT. Patient was taken to the IR suit, where a pigtail catheter was repositioned in the right pulmonary artery and 8mg of tPA was administered. The catheter was then manually rotated to macerate the clots in the right upper lobe. Subsequently, patient’s oxygen saturation improved to 92% with SBP 97mmHg.
DISCUSSION: Roughly 8% of patients with PE present with hemodynamic instability and circulatory collapse. These patients have either systolic blood pressure <90 mmHg for >15 minutes, hypotension requiring vasopressors or clear evidence of shock. In these patients, systemic thrombolysis has shown to decrease mortality, reduce recurrence of thromboembolism and improve hemodynamics, but is associated with 20% risk of hemorrhage and 2%-3% risk of hemorrhagic stroke. CDT can be employed in patient who are not candidates for systemic tPA. Currently, there are several CDTs available: ultrasound assisted thrombolysis, rheolytic embolectomy, suction embolectomy and thrombus fragmentation. A meta-analysis evaluating safety and efficacy of CDT showed a clinical success rate of 86.5%. The latest guidelines of ACCP recommend that interventional catheterization techniques should only be used in patients who are severely critical or have increase bleeding risk.
CONCLUSIONS: Several studies have demonstrated the efficacy of thrombolysis using catheter directed techniques in massive and submassive pulmonary embolisms. Techniques can also be combined, such as fragmentation with angioplasty, aspiration and catheter directed thrombolysis, to achieve better prognosis.
Reference #1: Imberti, D, Ageno, W., Manfredini, R., Fabbian, F., Salmi, R., et al. (2012). Interventional treatment of venous thromboembolism: A review. Thrombosis Research, 129(4), 418-425.
Reference #2: Kuo, W. T., Gould, M. K., Louie, J. D., Rosenberg, et al. (2009). Catheter-directed Therapy for the Treatment of Massive Pulmonary Embolism: Systematic Review and Meta-analysis of Modern Techniques. Journal of Vascular and Interventional Radiology, 20(11), 1431-1440.
Reference #3: Skaf, E., Beemath, A., Siddiqui, T., Janjua, M., Patel, N. R. (2007). Catheter-Tip Embolectomy in the Management of Acute Massive Pulmonary Embolism. The American Journal of Cardiology, 99(3), 415-420.
DISCLOSURE: The following authors have nothing to disclose: Ali Ahmed, Yuyang Zhang, Eran Rotem
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