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.

www.e-radiography.net/radpath/p/pe2.htm

Pulmonary Emboli www.nejm.org/.../nejm199702063360605_f1.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 Zhou et al Chinese Med J 2009:122:1723-1727 Aim: 1] dispersion of the central occlusive thrombus to the peripheral branches whereby the cross-section area is X2. 2] Increase the 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 Technique: The pigtail fragmentation system is rotated manually over a fixed wire and repeatedly advanced and withdrawn.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

Fragmentation time: 17 ± 8 min. 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%!

Partial recanalization and hemodynamic stabilization is feasible. 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 AngioJet 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). AngioJet 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. AngioJet 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 AngioJet therapy [shown in small studies ] are technically feasible and provide hemodynamic and clinical benefits. Further studies and development of dedicated technology are warranted.