1. Jomo Osborne Lung-2015 Baltimore, USA July 13 - 15, 2015

2. Jomo Osborne, MD Jomo Osborne, MD Brooklyn Hospital Center July 14, 2015 International Conference and Exhibition on Lung Disorders & Therapeutics – 2015 Catheter-directed thrombolysis in patients with acute pulmonary thromboembolism - A Case Series

3. Introduction Pulmonary thromboembolus (PE) is the sudden obstruction of the pulmonary artery or one of its branches usually by a blood clot that travels to the lung from a vein in the leg (DVT or deep vein thrombosis). It is estimated that PE affects between 300,000 to 600,000 people in the United States annually. The mortality rate for untreated PE is about 30 percent, with the majority of deaths occurring within the first few hours of the event. http://www.nhlbi.nih.gov/health/health-topics/topics/pe

4. Introduction Predisposing factors include surgery, trauma, cancer, immobilization, pregnancy, oral contraceptive use or HRT. Acute PE interferes with both the circulation and gas exchange. Right ventricular (RV) failure due to pressure overload is considered the primary cause of death in severe PE. PE may be clinically suspected when patient presents with dyspnea, hemoptysis, chest pain, or syncope. However, PE may be asymptomatic and be an incidental finding during autopsy or work-up for another disease. http://www.nhlbi.nih.gov/health/health-topics/topics/pe 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

5. Introduction Massive pulmonary embolism (PE) is characterized by hypotension and cardiac shock and is associated with mortality rates > 50%. Submassive PE is characterized by subclinical right ventricular dysfunction and normal blood pressure. Anticoagulation is the mainstay of management of PE. Management options for advanced therapy include fibrinolysis, catheter-assisted embolectomy, surgical embolectomy, and IVC filter insertion. While massive PE is treated aggressively with thrombolytic agents, or surgical or interventional procedures, advanced therapy is controversial with in submassive PE. http://www.nhlbi.nih.gov/health/health-topics/topics/pe 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

6. Introduction We successfully utilized Pharmacomechanical catheter-directed thrombolysis in three patients with acute pulmonary thromboembolism (PE). This methods was shown to safe and effective for preventing right ventricular collapse, cardiogenic shock, and death.

7. Methods and Materials The patients were: a 57 year-old woman with a history of hypertension and previous thyroid cancer which was treated with thyroidectomy, presented with a pulmonary arterial saddle embolus and right cardiac dysfunction; a 55 year-old woman on chemotherapy with a history of deep vein thrombosis (DVT), previous tumor-debulking and extended right hemicolectomy for metastatic leiomyosarcoma presented with a large central pulmonary embolus in the right main pulmonary artery without right ventricular strain; a 54 year-old man with a history of lower extremity DVT with a right main pulmonary artery embolus and right ventricular strain.

8. Methods and Materials Each patient was assessed through physical examination, electrocardiography, cardiac biomarkers, echocardiography, and chest computed tomography angiography. Based on the clot location in each patient, an EKOS catheter was placed in the main pulmonary artery or its branches, and tPA was infused at a rate of 1mg per hour over 10-24 hours. The follow-up CTA showed 75% to 100% clot reduction in each patient. Complications included a right-sided groin hematoma at the catheter-insertion site in one patient which required temporary discontinuation of thrombolytic and anti-coagulation therapy

9. Results and discussion

10. Conclusion Our observations of these three patients show that this method of treatment is a safe and effective initial measure to restore pulmonary artery blood flow in patients diagnosed with acute PE. However, it is still associated with the risk of complications.

11. Acknowledgement Suresh Srinivasan, MD Rush University Medical Center Department of Anesthesiology Sandeep Sirsi MD, FACS Brooklyn Hospital, Department of Surgery Armand Asarian MD, FACS Brooklyn Hospital, Department of Surgery Peter Pappas MD, FACS Brooklyn Hospital, Department of Surgery

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