Catheter-directed clot fragmentation using the Cleaner? device in a patient presenting with massive pulmonary embolism

摘要

Massive pulmonary embolism not amenable to systemic thrombolysis is a therapeutic challenge. Catheter directed clot fragmentation and thrombolysis have been efficacious in this setting. We describe successfully treating a massive pulmonary embolism with catheter-directed thrombolysis and clot fragmentation using local tPA, aspiration, and the Cleaner? device in a patient with an absolute contraindication to systemic thrombolysis. Keywords: Pulmonary embolism, catheter-directed thrombolysis, clot fragmentation, Cleaner? deviceINTRODUCTIONPulmonary embolus (PE) carries a significant mortality rate; however, not all pulmonary emboli are equal. The American Heart Association (AHA) recently released a stratification scheme for pulmonary emboli, categorizing them as massive, sub-massive, and low-risk, in order of decreasing mortality (1). Massive pulmonary emboli are defined by the AHA as those causing a systolic blood pressure of less than 90 mm Hg for greater than 15 minutes and/or requiring vasopressor support. Given the high mortality associated with hemodynamically significant PE and anticoagulation alone, the ACCP and AHA guidelines allow for consideration of escalation of therapy either through the administration of intravenous tPA, catheter directed therapy, or surgical embolectomy (1, 2).In a meta-analysis performed by Kuo et al (3), catheter directed clot fragmentation and a variable amount of aspiration and local lysis in the setting of massive PE was associated with an 86% success rate. In the analysis, ~70% of interventionalists used a rotating pigtail catheter for clot fragmentation. Multiple other fragmentation techniques have been used in both Europe and the United States (3). Here, we report the use of the Cleaner~(TM) device (Rex medical, Athens, TX) to mechanically fragment a large clot in the right pulmonary artery in a patient presenting with a massive pulmonary embolism and intracranial hemorrhage.CASE REPORTA 40 year-old Caucasian male with acromegaly was admitted for a planned inter-hemispheric trans-callosal resection of a recurrent pituitary macroadenoma. He had numerous previous macroadenoma resections, and a history of unprovoked lower extremity DVT and pulmonary embolism treated with six months of anticoagulation and no inferior vena cava filter placement. Post operatively, he developed generalized tonic-clonic seizures and was found to have a sagittal vein thrombosis and a parasagittal frontal cortex acute hemorrhage. Given the hemorrhage, full dose anticoagulation was not initiated, but he was placed on 5000 units of subcutaneous unfractionated heparin twice daily for DVT prophylaxis. Serial CT imaging confirmed no progression of the hemorrhage.On day 10 following his surgery, the patient developed acute shortness of breath and chest tightness. Objectively, he became tachycardic (HR 110) and tachypneic (RR 30), and desaturated on room air to 85%. An arterial blood gas revealed a pH of 7.46 (normal 7.40) with a pCO2 of 35mmHg (normal 40mmHg) and a pO2 of 59mmHg (normal>80mmHg) on a 100% FiO2 non-rebreather mask. His oxygen saturation only reached 92%. His blood pressure dropped from a baseline of 120/80 to 90/60. He was urgently sent for a chest CT which revealed an extensive pulmonary embolus filling the right and, to a lesser extent, left pulmonary arteries (Figure 1A–B). The pulmonary artery (PA), right atrium and right ventricle were distended (Figure 1C–D), and there was reflux of contrast into the IVC (Figure 1D). He had small infarcts in his right lung (Figure 1C). Another concerning finding was a large thrombus extending into the intra-hepatic inferior vena cava (Figure 1E). In addition, a Doppler study of his lower extremities confirmed the presence of left popliteal and left femoral thrombus. A transthoracic echocardiogram showed a severely dilated right ventricle and atrium with mild tricuspid regurgitation. Also noted was a dilated IVC without respiratory variability, implying a CVP >11mmHg (normal 0–2mmHg). The patient was immediately started on a heparin drip, and pulmonology, interventional radiology, and cardiothoracic surgery were consulted. Given the patient’s hemodynamic instability, inability to tolerate a major surgery, and the absolute contraindication (intracranial bleeding) to systemic thrombolysis, a catheter-directed approach was chosen. The risks and benefits of this approach have been carefully discussed with the patient and he was fully consented for the procedure. Open in a separate windowFigure 1 40 year old male patient with high clinical suspicion of acute PE. Axial images from a pulmonary arterial phase contrast-enhanced chest CT (GE scanner, mA: 490, kVP: 120, slice thickness: 1.25mm, 140 cc Omnipaque 300) A) and B) Large, expansile, central thrombus in the right pulmonary artery, and eccentric non-occlusive acute thrombus in the left pulmonary artery extending to the lower lobe branch. C) Enlarged right atrium and right ventricle with septal bowin