Abstract
Massive pulmonary embolism with hemodynamic instability is a life-threatening condition requiring immediate treatment. Urgent thrombectomy or thrombolysis is commonly used for the treatment of this condition. However, surgery is associated with high mortality rate and many patients have contraindications to thrombolytic therapy and are at high risk for bleeding. Cather-based intervention has gained increasing popularity particularly in patients with contraindication to thrombolytic therapy or at high risk for surgical thrombectomy. Catheter-based thrombus removal can be achieved by many means such as suction, fragmentation, extraction or rheolytic thrombectomy. We present a case of an elderly lady who suffered from acute massive pulmonary embolism with hemodynamic compromise successfully treated with AngioVac catheter system (AngioDynamics, Albany, NY) with full recovery.
1
Introduction
Pulmonary embolism (PE) is associated with high mortality and morbidity and can be fatal in up to 10% of the patients . PE is considered massive when occlusion of pulmonary artery is > 50% of its cross-sectional area resulting in hemodynamic compromise . If this obstruction exceeds 75%, the right ventricle has to acutely generate a systolic pressure greater than 50 mm Hg that can lead to right ventricular failure and death. Eighty-five percent of death in patients with massive PE occurs in the first 6 hours . In the case of massive PE, embolectomy or systemic thrombolysis in addition to anticoagulation could rapidly reverse right ventricular failure and cardiogenic shock. However, major contraindications, such as prior surgery, trauma, stroke, or advanced cancer, make approximately one third of the patients with massive PE ineligible for thrombolysis . Surgical embolectomy is an effective treatment of this condition but it requires a dedicated team and system in place and is associated with significant morbidity . With the advancement in interventional procedures, catheter-based technology has gained increasing popularity that can combine clot destruction with local thrombolysis . Catheter-based thrombus removal can be achieved by many means such as suction, fragmentation, extraction or rheolytic thrombectomy . We present a case of an elderly lady who suffered from acute massive pulmonary embolism with hemodynamic compromise successfully treated with suction thrombectomy utilizing off-label use of AngioVac catheter system (AngioDynamics, Albany, NY) with full recovery.
2
Case
A 66-year-old female with a medical history significant for recurrent endometrial cancer and diabetes mellitus, presented with progressive dyspnea on exertion and generalized body weakness. Examination revealed tachycardia and hypoxia requiring 4 L of oxygen. Respiratory examination was clear to auscultation. Troponin was positive at 0.314 and BNP was 1245. Twelve-lead EKG showed sinus tachycardia and left-axis deviation, with poor R-wave progression. Two-dimensional echocardiogram revealed right ventricular free wall hypokinesis with spared apical contraction (Mc Connells sign) suggestive of acute pulmonary embolism. Subsequent chest CT revealed saddle pulmonary embolus extending into right and left pulmonary arteries as well as lobar arteries. Evidence of right heart strain was also present. The patient was given intravenous bolus of heparin and started on continuous heparin infusion. She developed hypotension and tachycardia consistent with cardiogenic shock. Pulmonary angiogram confirmed the diagnosis of saddle embolus in the main pulmonary artery extending into right upper and right lower pulmonary artery [ Fig. 1 (a) and (b) ]. She was deemed to be not a thrombolytic or surgical candidate. Due to the need for equipment to be setup, the thrombectomy was performed 3 hours later. An 8-French sheath was sutured into the right common femoral artery and a 4-French sheath was sutured in the left common femoral vein and the patient was transferred out of the interventional suite. The second procedure was performed under general anesthesia. Using an Amplatz Stiff wire and serial dilations, the right 8- French venous sheath was replaced by a 26-French Angiovac catheter ( Fig. 2 ) The left 4-French venous sheath was replaced by a 17-French Angiovac circulator tubing. An 8-French long venous catheter was placed in the main pulmonary artery, and was exchanged over the j wire for Angiovac thrombectomy catheter distal to right pulmonary artery ( Fig. 3 ). The embolus was partially removed by suction. Then central venous access was gained through internal jugular vein and a 6-French pigtail catheter was directed to the right ventricle. DSA mode right ventricular angiogram confirmed partial removal of large saddle embolus from pulmonary arteries ( Fig. 4 ). Next, 10-mg of tPA was administered into the pulmonary artery through the pigtail connector. At the end of procedure the sheaths were withdrawn and hemostasis was achieved using manual compression. The patient remained in critical condition during the procedure requiring pressor support. She was observed in the ICU after the procedure where she made a rapid recovery and was discharged 7 days later. Follow-up echocardiogram showed resolution of right ventricular hypokinesia. On subsequent visits, she was fully ambulatory and stable without any symptoms on oral anticoagulation.
2
Case
A 66-year-old female with a medical history significant for recurrent endometrial cancer and diabetes mellitus, presented with progressive dyspnea on exertion and generalized body weakness. Examination revealed tachycardia and hypoxia requiring 4 L of oxygen. Respiratory examination was clear to auscultation. Troponin was positive at 0.314 and BNP was 1245. Twelve-lead EKG showed sinus tachycardia and left-axis deviation, with poor R-wave progression. Two-dimensional echocardiogram revealed right ventricular free wall hypokinesis with spared apical contraction (Mc Connells sign) suggestive of acute pulmonary embolism. Subsequent chest CT revealed saddle pulmonary embolus extending into right and left pulmonary arteries as well as lobar arteries. Evidence of right heart strain was also present. The patient was given intravenous bolus of heparin and started on continuous heparin infusion. She developed hypotension and tachycardia consistent with cardiogenic shock. Pulmonary angiogram confirmed the diagnosis of saddle embolus in the main pulmonary artery extending into right upper and right lower pulmonary artery [ Fig. 1 (a) and (b) ]. She was deemed to be not a thrombolytic or surgical candidate. Due to the need for equipment to be setup, the thrombectomy was performed 3 hours later. An 8-French sheath was sutured into the right common femoral artery and a 4-French sheath was sutured in the left common femoral vein and the patient was transferred out of the interventional suite. The second procedure was performed under general anesthesia. Using an Amplatz Stiff wire and serial dilations, the right 8- French venous sheath was replaced by a 26-French Angiovac catheter ( Fig. 2 ) The left 4-French venous sheath was replaced by a 17-French Angiovac circulator tubing. An 8-French long venous catheter was placed in the main pulmonary artery, and was exchanged over the j wire for Angiovac thrombectomy catheter distal to right pulmonary artery ( Fig. 3 ). The embolus was partially removed by suction. Then central venous access was gained through internal jugular vein and a 6-French pigtail catheter was directed to the right ventricle. DSA mode right ventricular angiogram confirmed partial removal of large saddle embolus from pulmonary arteries ( Fig. 4 ). Next, 10-mg of tPA was administered into the pulmonary artery through the pigtail connector. At the end of procedure the sheaths were withdrawn and hemostasis was achieved using manual compression. The patient remained in critical condition during the procedure requiring pressor support. She was observed in the ICU after the procedure where she made a rapid recovery and was discharged 7 days later. Follow-up echocardiogram showed resolution of right ventricular hypokinesia. On subsequent visits, she was fully ambulatory and stable without any symptoms on oral anticoagulation.
