title: Combined modality of mechanical breakdown and intraembolus thrombolysis in failed systemic thrombolysis of subacute pulmonary embolism patients.
abstract: OBJECTIVE
  Acute massive pulmonary embolism with failed systemic thrombolysis has a high morbidity and mortality with few treatment options available. This study assesses the role of combined modality of mechanical fragmentation and intralesional thrombolysis in failed systemic thrombolysis.
  
  
  METHODS
  Seven (13.5%) of 52 patients with massive pulmonary embolism with persistent cardiogenic shock that failed systemic thrombolysis underwent imaging to confirm pulmonary embolism, and then mechanical fragmentation and intralesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4,400 IU/kg over 10 minutes followed by 4,400 IU/kg per hour over 24 hours).
  
  
  RESULTS
  Four (57.1%) of 7 were unsuccessfully thrombolyzed outside the hospital by urokinase, 2 (28.6%) with recombinant tissue-type plasminogen activator (rtPA) and 1 (14.3%) with streptokinase systemically before 24-48 hours of admission. At presentation, average heart rate and shock index were 121.7/min and 1.45, respectively. Average systolic pulmonary arterial pressure was 73 ± 2.65 mmHg at presentation, and postoperatively was significantly reduced to 39.7 ± 10.44 mmHg (P < 0.001). Mortality at 24 hours, 30 days, and 2 years follow-up was 0% (0/7).
  
  
  CONCLUSIONS
  Mechanical breakdown of thrombus followed by urokinase infusion may be a cost-effective, minimally invasive, and potentially life-saving procedure for the management of acute massive pulmonary embolism. Randomized controlled trials are required to compare this new strategy to contemporary conventional approaches.
authors.affiliation: Department of Pulmonary and Critical Care, Hero DMC Heart Institute, Ludhiana, Punjab, India. bishav_68@yahoo.co.in
authors.forename: Bishav
authors.initials: B
authors.lastname: Mohan
authors.forename: Vineet
authors.initials: V
authors.lastname: Mahajan
authors.forename: Shibba T
authors.initials: ST
authors.lastname: Chhabra
mesh_terms: D000208:Acute Disease; D000328:Adult; D006328:Cardiac Catheterization; D003131:Combined Modality Therapy; D017128:Embolectomy; D005260:Female; D006305:Health Status Indicators; D006339:Heart Rate; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000188:drug therapy* / Q000601:surgery / Q000628:therapy; D012770:Shock, Cardiogenic / Q000188:drug therapy* / Q000601:surgery / Q000628:therapy; D015912:Thrombolytic Therapy / Q000379:methods*; D017211:Treatment Failure; D014568:Urokinase-Type Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D014568:Urokinase-Type Plasminogen Activator