Chest
Volume 134, Issue 1, July 2008, Pages 54-60
Journal home page for Chest

Original Research
Pulmonary Embolism
Combined Clot Fragmentation and Aspiration in Patients With Acute Pulmonary Embolism*

https://doi.org/10.1378/chest.07-2656Get rights and content

Background

Massive angiographic pulmonary embolism (PE) with right ventricular dysfunction (RVD) is associated with a high early mortality rate. The therapeutic alternatives for this condition include thrombolysis, surgical embolectomy, or percutaneous mechanical thrombectomy (PMT). We describe our experience using PMT in patients with massive PE and RVD with unsuccessful thrombolysis, increased bleeding risk, or major contraindications for thrombolytic therapy.

Methods

Clinical, hemodynamic, and angiographic parameters prior to and following PMT were evaluated. Our primary objective was to describe the incidence of in-hospital cardiovascular death, and of major and minor complications. Mid-term outcomes included analysis of occurrence of cardiovascular death, recurrent pulmonary embolism, change of New York Heart Association functional class, and hospital readmission.

Results

From July 2004 to May 2007, 69 patients were referred to the cardiac catheterization laboratory with a diagnosis of acute PE, 18 of whom met the criteria for massive PE and are the subject of this study. All patients underwent thrombus fragmentation using a pigtail catheter that was complemented in 13 patients with thrombus aspiration. A percutaneous thrombectomy device (Aspirex; Straub Medical; Wangs, Switzerland) was used in 11 patients. Hemodynamic, angiographic, and blood oxygenation parameters improved after the procedure. A significant increase was observed for systolic systemic BP (74.3 ± 7.5 mm Hg vs 89.4 ± 11.3 mm Hg, p = 0.001) [mean ± SD], as was a decrease in mean pulmonary artery pressure (37.1 ± 8.5 mm Hg vs 32.3 ± 10.5 mm Hg, p = 0.0001). The in-hospital major complications rate was 11.1%; one patient died from refractory shock, and one patient had intracerebral hemorrhage with minor neurologic sequelae. No cardiovascular deaths or recurrent pulmonary thromboembolism were documented during clinical follow-up (12.3 ± 9.4 months).

Conclusions

In patients with massive PE, RVD and major contraindications to thrombolytic therapy, increased bleeding risk, failed thrombolysis, or unavailable surgical thrombectomy, PMT appears to be a useful therapeutic alternative.

Section snippets

Patients

During the period from July 2004 to May 2007, 69 patients were referred to the cardiac catheterization laboratory with a diagnosis of PE, of whom 18 patients met the criteria for massive PE based on the angiographic evidence of a thrombus image in a main pulmonary branch or in two or more lobar branches, and one or more criteria of RVD, the subject of this report. This study was approved by the institutional review board, and informed consent was obtained from all patients.

The criteria applied

Results

Mean age was 51.4 ± 4 years, with male gender predominance (76%). Baseline characteristics of the patients are described in Table 1. The most frequent risk factors were prior deep vein thrombosis and obesity (47.1%); three of our patients were pregnant (23.5%). Among the clinical manifestations, most patients presented dyspnea (94.4%), chest pain (88.9%), and cough (61.1%). sSBP level was 95.3 ± 10.8 mm Hg, with 44.4% of patients having sSBP < 90 mm Hg prior to the procedure; mean heart rate

Discussion

The clinical spectrum of RVD secondary to acute PE is varied. Patients with RVD and sSBP > 90 mm Hg have a high rate of PE recurrence and related death risk. The mortality rate in this group may reach 12.8%, and 10% progress to cardiogenic shock, which is considered secondary to recurrent PE in 50% of the cases.11, 12, 13, 14 Treatment of this group is controversial. The Management Strategy and Prognosis of Pulmonary Embolism Registry reported a 30-day mortality rate of 4.7% with thrombolysis,

Conclusions

The main objective of PMT is to revert RVD or cardiogenic shock secondary to PE. Invasive treatment should be limited to the main or lobar arteries and hemodynamic improvement criteria should be used as guidance to conclude the procedure, regardless of the angiographic result. The device employed in this series (Aspirex) was found to be safe and was not associated with damage to cardiac structures although experience with its use in a larger number of patients is required for a better

References (31)

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    Citation Excerpt :

    It then through its mechanism of action causes fragmentation, maceration, and clearing of the thrombus. Although more widely used in acute deep venous thromboembolism or dialysis access, the Aspirex catheter has some limited evidence to support its use in the treatment of high-risk PE.20,21 The FlowTriever system (Inari Medical, Irvine, CA) uses a wide-bore, hydrophilic 20F aspiration guide catheter that can easily be delivered into the PAs over a standard supportive guidewire.

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The authors have no actual or potential conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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