Aspiration with Thrombolysis for Massive Pulmonary Embolism On

Aspiration with Thrombolysis for Massive Pulmonary Embolism On Topaz*, MD, Kristine Owen, MD Division of Cardiology Charles George VAMC Asheville, North Carolina *Professor of Medicine Duke University School of Medicine Raleigh, NC

On Topaz, MD I have no real or apparent conflicts of interest to report.

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Pulmonary Emboli www. nejm. org/. . . /nejm 199702063360605_f 1. jpeg

Massive PE • Massive PE is clinically manifested by severe hemodynamic deterioration, hypoxemia, RV dysfunction, accompanying LV impairment and critical respiratory/metabolic failure. • This condition is associated with a very high early mortality rate.

Massive PE • The mainstay treatment strategy is either thrombolysis or surgical embolectomy. • Adjunctive catheter-based aspiration/fragmentation- an option. • Percutaneous mechanical thrombectomy (PMT) is an emerging therapeutic approach.

Massive PE-Lytic Therapy • Only to be given in patients with confirmed PE. • Indications: severe hypoxemia, persistent hypotension, large perfusion defects or clot burden, RV dysfunction, PFO, or visible clot in RA/RV. • The thrombolytic therapy activates plasminogen to form plasmin, thus, accelerating thrombolysis. • Short term physiologic benefits (improved PA pressure, RV function, and lung perfusion) have not been consistently shown to have a mortality benefit.

Massive Pulmonary Embolism. Catheter-directed Lytics • Thrombolytic agents have been infused into the pulmonary artery via a pulmunary catheter. • No clear benefit vs. peripheral venous infusion. • Infusion of thrombolytic therapy directly into the occlusive thrombus may become an essential step for improving the outcome.

Pulmonary Angiogram in massive PE: potential target for PMT

The fragmentation approach: Pigtail Rotational Catheter

Fragmentation Aim: • 1] dispersion of the central occlusive thrombus to the peripheral branches whereby the cross-section area is X 2. • 2] Increase thrombus surface area for acceleration of local pharmacotherapy. Technique: • The pigtail fragmentation system is rotated manually over a fixed wire and repeatedly advanced and withdrawn. • Adjunct thrombolytic therapy can follow. • Zhou et al Chinese Med J 2009: 122: 1723 -1727

Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter Schmitz-Rode, J Am Coll Cardiol, 2000; 36: 375 -380 RESULTS : • Small study: 20 patients • Placement and navigation of the fragmentation catheter was technically feasible and rapid. • Fragmentation time: 17 ± 8 min.

• Rapid and safe improvement of the hemodynamic condition observed in 1/3 of the treated patients. • This method appeared useful especially in high-risk patients. • The fragmentation method can be complimented by lytic therapy in order to accelerate thrombolysis. • Alternative to surgical embolectomy. • Overall mortality 20%!

Catheter fragmentation of acute massive pulmonary thromboembolism NAKAZAWA British Journal Radiology 2008: 81, 848 -854 • 25 patients • Thrombus fragmentation with a rotational pigtail catheter followed by aspiration with a guiding catheter. • Partial recanalization and hemodynamic stabilization is feasible. • Important adverse effects : distal embolization and increase in PAP can occur with fragmentation.

Rheolytic Angio. Jet Therapy

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism. Chechi et al CCI 2009; 73: 506 -13 • Angiographic massive PE in 25 patients. • Technical success 92%. • A significant improvement in the thrombotic obstruction and antegrade perfusion. • 4 (16%) patients suffered major bleeding. • 8 (32%) died in-hospital. • All survivors were alive at long-term follow-up (35. 5 +/- 21. 7 months) (3 expired due to cancer and AMI). • Angio. Jet RT is feasible and safe for most patients with acute massive/submassive PE.

Massive Pulmonary Embolism. PMT Technical Notes • Yield of aspiration catheters has been very limited due to their small size versus that of the target thrombus. • Utilization of Angiojet requires adequate guide wire support and consideration of severe reflex bradycardia. • Angio. Jet operators should be prepared to administer intra-thrombus lytic and perform segmental pulmonary artery angioplasty and stenting.

Summary: Aspiration with Thrombolysis for Massive PE • Massive PE causes hemodynamic catastrophe and early high mortality rate. • Current treatment modalities carry limited efficacy. • Lytic therapy accelerates clot lysis, however, it provides only short term hemodynamic improvement. • Fragmentation/Aspiration and Angio. Jet therapy [shown in small studies ] are technically feasible and provide hemodynamic and clinical benefits. • Further studies and development of dedicated technology are warranted.