Catheter-directed interventions for acute pulmonary embolism

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Presentation transcript:

Catheter-directed interventions for acute pulmonary embolism Efthymios D. Avgerinos, MD, Rabih A. Chaer, MD Journal of Vascular Surgery Volume 61, Issue 2, Pages 559-565 (February 2015) DOI: 10.1016/j.jvs.2014.10.036 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 Suggested algorithm for the management of acute pulmonary embolism (PE). RV, Right ventricle; SBP, systolic blood pressure. ∗Hypokinesis on echocardiography or elevated troponin I or T with local thresholds (values exceeding the 99th percentile with coefficient of variability <10%) or brain natriuretic peptide >90 pg mL−1 or amino-terminal pro-B-type natriuretic peptide >900 pg mL−1. ‡Absolute contraindications: any prior intracranial hemorrhage; known structural intracranial cerebrovascular disease or neoplasm; ischemic stroke within 3 months; suspected aortic dissection; active bleeding or bleeding diathesis; recent spinal or cranial/brain surgery; recent closed head or facial trauma with bone fracture or brain injury. Relative contraindications: age ≥75 years; current use of anticoagulation; pregnancy; noncompressible vascular punctures; traumatic or prolonged cardiopulmonary resuscitation; recent internal bleeding (2-4 weeks); history of chronic, severe, and poorly controlled hypertension; severe uncontrolled hypertension on presentation; dementia; remote (3 months) ischemic stroke; major surgery within 3 weeks. Journal of Vascular Surgery 2015 61, 559-565DOI: (10.1016/j.jvs.2014.10.036) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 A 60-year-old otherwise healthy man presented with severe chest tightness, dyspnea, and near-syncope. Computed tomography angiography showed saddle pulmonary embolism (PE) with a large thrombus burden in the main segmental branches (R > L). He had worsening respiratory function and right-sided heart strain but no hemodynamic decompensation. Catheter-directed thrombolysis was performed. a, Pulmonary angiogram showing bilateral segmental thrombus (arrows). b, EKOS catheters were placed within the thrombus, and a lytic infusion was initiated (the arrows indicate the multiside hole infusion segments of the catheters and the inner wire segments with ultrasound microtransducers). c, Lysis check at 16 hours showed thrombus resolution, along with decreased oxygen requirements and normalization of right ventricular function. Journal of Vascular Surgery 2015 61, 559-565DOI: (10.1016/j.jvs.2014.10.036) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 Massive pulmonary embolism (PE; right ventricular strain and hemodynamic decompensation) in a patient with recent surgery and with intrapulmonary bleed due to the pulmonary infarct. a, Intraoperative pulmonary angiogram indicating bilateral thrombus (arrows) (L > R). b, Pigtail rotation within the major clot burden. c, Aspiration thrombectomy with a 10F Pronto catheter (Vascular Solutions, Minneapolis, Minn). d, Extracted thromboembolic material. Journal of Vascular Surgery 2015 61, 559-565DOI: (10.1016/j.jvs.2014.10.036) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 Submassive pulmonary embolism (PE; right ventricular strain without hemodynamic decompensation) with increasing oxygen requirement, in a young patient, after brain abscess evacuation. a, Pulmonary angiogram showing bilateral thrombus (R > L) (the arrow points to the occluded right main pulmonary artery). b, AngioVac (AngioDynamics, Latham, NY) aspiration from a jugular approach. c, Extracted thromboembolic material. Cardiopulmonary parameters subsequently normalized. Journal of Vascular Surgery 2015 61, 559-565DOI: (10.1016/j.jvs.2014.10.036) Copyright © 2015 Society for Vascular Surgery Terms and Conditions