title: Catheter-directed embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis.
abstract: OBJECTIVE
  The standard medical management for patients in extremis from massive pulmonary embolism (PE) is systemic thrombolysis, but the utility of this treatment relative to catheter-directed intervention (CDI) is unknown. We evaluated the effectiveness of CDI as part of a treatment algorithm for life-threatening PE.
  
  
  METHODS
  A retrospective review was performed on 70 consecutive patients with suspected acute PE over a 10-year period (from 1997 to 2006) who had been referred for pulmonary angiography and/or intervention. The criteria for study inclusion were patients who received CDI due to angiographically confirmed massive PE and hemodynamic shock (shock index, > or = 0.9). CDI involved suction embolectomy and fragmentation with or without catheter thrombolysis.
  
  
  RESULTS
  Twelve patients were treated with CDI. There were seven men and five women (mean age, 56 years; age range, 21 to 80 years). Seven patients (58%) were referred for CDI after failing systemic infusion with 100 mg of tissue plasminogen activator, and five patients (42%) had contraindications to systemic thrombolysis. Catheter-directed fragmentation and embolectomy were performed in all patients (100%). Additionally, catheter-guided thrombolysis was performed in eight patients (67%). Technical success was achieved in 12 of 12 cases (100%). There were no major procedural complications (0%). Significant hemodynamic improvement (shock index, < 0.9) was observed in 10 of 12 cases (83%). The remaining two patients (17%) died secondary to cardiac arrest within 24 h. Ten of 12 patients (83%) survived and remained stable until hospital discharge (mean duration, 20 days; range, 3 to 51 days).
  
  
  CONCLUSIONS
  In the setting of hemodynamic shock from massive PE, CDI is potentially a life-saving treatment for patients who have not responded to or cannot tolerate systemic thrombolysis.
authors.affiliation: Department of Radiology, Stanford University Medical Center, Stanford, CA. Electronic address: wkuo@stanford.edu.
authors.forename: William T
authors.initials: WT
authors.lastname: Kuo
authors.affiliation: Department of Radiology, Stanford University Medical Center, Stanford, CA.
authors.forename: Maurice A A J
authors.initials: MAAJ
authors.lastname: van den Bosch
authors.affiliation: Department of Radiology, Stanford University Medical Center, Stanford, CA.
authors.forename: Lawrence V
authors.initials: LV
authors.lastname: Hofmann
authors.affiliation: Department of Radiology, Stanford University Medical Center, Stanford, CA.
authors.forename: John D
authors.initials: JD
authors.lastname: Louie
authors.affiliation: Department of Radiology, Stanford University Medical Center, Stanford, CA.
authors.forename: Nishita
authors.initials: N
authors.lastname: Kothary
authors.affiliation: Department of Radiology, Stanford University Medical Center, Stanford, CA.
authors.forename: Daniel Y
authors.initials: DY
authors.lastname: Sze
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002406:Catheterization, Peripheral; D015331:Cohort Studies; D017128:Embolectomy; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D019233:Retreatment; D012189:Retrospective Studies; D015912:Thrombolytic Therapy; D017211:Treatment Failure
chemical_list: D005343:Fibrinolytic Agents