Rheolytic Thrombectomy with or without Adjunctive Indwelling Pharmacolysis in Patients Presenting with Acute Pulmonary Embolism Presenting with Right Heart Strain andor Pulseless Electrical Activity

Abstract EN

Purpose.

To evaluate the safety and efficacy of the Possis rheolytic thrombectomy with or without indwelling catheter-directed pharmacolysis for the treatment of massive pulmonary embolus in patients presenting with right heart strain and/or a pulseless electrical activity (PEA).

Materials and Methods.

Retrospective review of patients undergoing pulmonary pharmacolysis was performed (07/2004–06/2009).

Pre- and posttreatment Miller index scoring weres calculated and compared.

Patients were evaluated for tPA doses, ICU stay, hospital stay, and survival by Kaplan-Meier analysis.

Results.

11 patients with massive PE were found, with 10/11 presenting with a Miller score of >17 (range: 16–27, mean: 23.2).

CTPA and/or echocardiographic evidence of right heart strain was found in 10/11 patients.

3 (27%) patients presented with a PEA event.

Two (18%) patients had a contraindication to pharmacolysis and were treated with mechanical thrombectomy alone.

The intraprocedural mortality was 9% (n=1/11).

Of the 10 patients who survived the initial treatment, 7 patients underwent standard mechanical thrombectomy initially, while 5 received power pulse spray mechanical thrombectomy.

Eight of these 10 patients underwent adjunctive indwelling catheter-directed thrombolysis.

The mean catheter-directed infusion duration was 18 hours (range of 12–26 hours).

The average intraprocedural, infusion, and total doses of tPA were 7 mg, 19.7 mg, and 26.7 mg, respectively.

There was a 91% (10/11) technical success rate.

The failure was the single mortality.

Average reduction in Miller score was 9.5 or 41% (P=0.009), obstructive index of 6.4 or 47% (P=0.03), and perfusion index of 2.7 or 28% (P=0.05).

Average ICU and hospital stay were 7.4 days (range 2–27 days) and 21.3 days (range 6–60 days), respectively.

Intent to treat survival was 90% at 6, 12, and 18 months.

Conclusion.

Rheolytic thrombectomy with or without adjunctive catheter-directed thrombolysis provides a safe and effective method for treatment of acute PE in patients who present with right heart strain and/or a PEA event.