title: Endovascular treatment of a haemodynamically unstable massive pulmonary embolism using fibrinolysis and fragmentation. Experience with 111 patients in a single centre. Why don't we follow ACCP recommendations?
abstract: BACKGROUND
  Fibrinolysis is recommended in several consensus documents for the treatment of a haemodynamically unstable massive pulmonary embolism (HUMPE).
  
  
  METHODS
  A total of 111 patients were treated in a single centre from January 2001 to December 2009. They were 55 males and 56 females diagnosed with HUMPE (systolic arterial pressure>90 mmHg) with at least two of the following criteria: Miller index>0, ventricular dysfunction, and need of vasoactive drugs. Local fibrinolysis with urokinase was performed in all cases, and fragmentation with a pig-tail catheter in the majority of them. An inferior vena cava (IVC) filter was implanted in 94 patients as a prophylactic measure.
  
  
  RESULTS
  Technical success was 100%. The Miller index improved from 0.7 ± 0.12, pre-treatment, to 0.09 ± 0.16. The mean pulmonary arterial pressure fell from 39.93 ± 7.0 mmHg to 20.47 ± 3.3 mmHg in the 30-90 days review. Of the 94 patients with IVC filters implanted, 79% were withdrawn satisfactorily. Seven patients died: 3 due to their neoplasia, 3 due to right cardiac failure at 1, 7 and 30 days, and another died of a brain haemorrhage in the first 24 hours. There were complications in 12.6% of the cases, of which 4.5% were major.
  
  
  CONCLUSIONS
  Local fibrinolysis with fragmentation achieves a rapid return to normal of the pulmonary pressure and is a safe and effective method for the treatment of HUMPE.
authors.affiliation: Grupo de Investigación Técnicas de Mínima Invasión, Universidad de Zaragoza, Añadir Unidad de Cirugía Minimamente Invasiva Guiada por Imagen, Hospital Cínico Universitario Lozano Blesa, Zaragoza, Spain. mgregori@unizar.es
authors.forename: Miguel Angel
authors.initials: MA
authors.lastname: de Gregorio
authors.forename: Alicia
authors.initials: A
authors.lastname: Laborda
authors.forename: Ignacio
authors.initials: I
authors.lastname: de Blas
authors.forename: Joaquín
authors.initials: J
authors.lastname: Medrano
authors.forename: Antonio
authors.initials: A
authors.lastname: Mainar
authors.forename: Mikel
authors.initials: M
authors.lastname: Oribe
mesh_terms: D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy; D057510:Endovascular Procedures; D005260:Female; D019983:Guideline Adherence; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011655:Pulmonary Embolism / Q000503:physiopathology* / Q000628:therapy*; D012189:Retrospective Studies; D015912:Thrombolytic Therapy