Abstract 496: Large Pulmonary Embolism Treated with a Novel Percuatneous Catheter-Directed, Ultrasound-Assisted Low Dose Thrombolysis
Background Massive Pulmonary embolism (PE) is a life threatening diagnosis. Survival is dependent on the timing and availability of intravenous alteplase. In those who survive; recurrent PE, pulmonary hypertension and cor pulmonale are the long term sequelae.
Case We describe a 63 year old morbidly obese male (weight 470 lbs) presenting with increasing dyspnea. A CT scan of the chest revealed massive clots in bilateral pulmonary arteries and right ventricular (RV) strain.
Approximately 6 months prior to presentation he was diagnosed to have PE and was treated with warfarin. Warfarin was discontinued after 6 months as he was asymptomatic and CT scan showed resolution of clots. In the past few weeks he started to smoke and also complained of black stools.
Due to high risk presentation, history of melena in the recent past and dyspnea at rest, he was offered percutaneous therapy for PE. Using single internal jugular venous approach, right heart catherterization and pulmonary angiography was performed. Bilaterally ultrasound assisted- thrombolysis infusion catheters were placed in the pulmonary arteries. Alteplase was infused at low dose; total dose infused was 24 mg over 19 hours (Typical intravenous dose is 100 mg). Baseline hemodynamics showed severe pulmonary hypertension. Follow up angiogram showed almost complete resolution of clots and complete improvement in symptoms. Work up revealed Anti-Thrombin III deficiency. He was treated bivalirudin and discharged on warfarin. Follow-up testing showed improved RV pressures.
Discussion The mortality rate for acute PE is 2-6% in those with hemodynamic stability, and 30% or more in those with shock or unstable hemodynamics. Catheter-directed local thrombolysis should be considered as a therapy in those with sub-massive and massive PE with the advantage of significantly lower thrombolytic dose (almost 75% lower) with minimal bleeding risk. The ultrasound energy in this thrombolytic EKOS@ catheter helps loosen the clot via mechaincal energy, allowing lower dose of thrombolytics to be used locally. Ongoing studies utilizing this technology such as SEATTLE-II and ULTIMA will
offer further evidence based guidelines to manage acute pulmonary embolism.
- © 2013 by American Heart Association, Inc.