Combined clot fragmentation and aspiration in patients with acute pulmonary embolism.
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.
Eid-Lidt
Guering
G
Department of Interventional Cardiology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano No 1, Tlalpan, CP 14080, Mexico City, Mexico. guering@yahoo.com
Gaspar
Jorge
J
Sandoval
Julio
J
de los Santos
Félix Damas
FD
Pulido
Tomás
T
González Pacheco
Héctor
H
Martínez-Sánchez
Carlos
C
D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000502:physiology; D002404:Catheterization; D000075202:Contraindications; D005260:Female; D006470:Hemorrhage / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011651:Pulmonary Artery / Q000502:physiology; D011655:Pulmonary Embolism / Q000401:mortality / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013396:Suction / Q000379:methods*; D017131:Thrombectomy / Q000379:methods*; D015912:Thrombolytic Therapy; D013927:Thrombosis / Q000401:mortality / Q000601:surgery*; D016896:Treatment Outcome; D018497:Ventricular Dysfunction, Right / Q000503:physiopathology