Chest
Volume 132, Issue 2, August 2007, Pages 657-663
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Special Feature
Catheter Embolectomy for Acute Pulmonary Embolism

https://doi.org/10.1378/chest.07-0665Get rights and content

Massive pulmonary embolism (PE) is a life-threatening condition with a high early mortality rate due to acute right ventricular failure and cardiogenic shock. As soon as the diagnosis is suspected, an IV bolus of unfractionated heparin should be administered. In addition to anticoagulation, rapid initiation of systemic thrombolysis is potentially life-saving and therefore is standard therapy. Many patients with massive PE cannot receive thrombolysis because of an increased bleeding risk, such as prior surgery, trauma, or cancer. In these patients, catheter or surgical embolectomy are helpful for rapidly reversing right ventricular failure. Catheter thrombectomy appears to be particularly useful if surgical embolectomy is not available or the patient has contraindications to surgery. Although no controlled clinical trials are available, data from cohort studies indicate that the clinical outcomes after surgical and catheter embolectomy may be comparable.

Section snippets

Indications for Catheter Intervention

In patients with massive PE, systemic thrombolysis5 or surgical embolectomy6 in addition to anticoagulation rapidly reverse right ventricular failure and cardiogenic shock. However, approximately one third of the patients with massive PE are not eligible for thrombolysis because of major contraindications, such as prior surgery, trauma, stroke, or advanced cancer.7 PE thrombolysis is associated with a particularly high risk of bleeding complications. Among 304 patients from the International

Pulmonary Angiography for Massive PE

Patients who undergo invasive pulmonary angiography or catheter thrombectomy require continuous hemodynamic and ECG monitoring. The most common venous access sites are the common femoral or internal jugular veins.

In patients with acute onset of massive PE, the right ventricular systolic pressure typically is in the range of 40 to 60 mm Hg. Patients with chronic PE or underlying cardiopulmonary disorders may generate higher right ventricular systolic pressure values prior to the development of

Percutaneous Catheter Devices

The literature on catheter intervention in patients with acute PE is quite limited and is made up of small cases series. Percutaneous catheter intervention using various catheter devices has been reported in > 300 patients. In a review of the available literature, the overall clinical success rate, defined as immediate hemodynamic improvement, was > 80% (Table 111121314151617181920212223242526272829303132333435363738394041424344). The reported mortality rates range from 0 to 25% for the various

Catheter-Directed Thrombolyis

Catheter-directed thrombolytic therapy with intrapulmonary administration of a thrombolytic agent has been used by several investigators.53545556 It aims to accelerate clot lysis and achieve rapid reperfusion of the pulmonary arteries. The technique requires positioning of an infusion catheter within the embolus, with injection of a bolus of thrombolytic drug followed by a continuous infusion. The following intrapulmonary thrombolytic regimens have been used in combination with a therapeutic

Complications of Catheter Interventions

Rare but serious PE catheter thrombectomy complications include pericardial tamponade and pulmonary hemorrhage. The most serious complication is the perforation or dissection of a major pulmonary arterial branch that may cause massive pulmonary hemorrhage and immediate death. The risk of perforation increases when vessels < 6 mm in diameter are being treated.57 The myocardium of the right ventricle, particularly the right ventricular outflow tract, is thin and fragile, and caution is warranted

Conclusions

Catheter intervention is currently being performed in patients with acute PE and arterial hypotension or cardiogenic shock in whom an increased bleeding risk precludes the administration of systemic standard-dose fibrinolysis. Catheter thrombectomy also is useful in situations in which surgical embolectomy is not feasible or rapidly available. Due to the lack of data, catheter thrombectomy should currently not be used in hemodynamically stable PE patients. In the future, the indication for

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      Citation Excerpt :

      It requires the retrieval of the device and the thrombus as a unit. Conventional vascular access sheaths are not suitable for aspiration of large thrombus because it usually gets trapped within the sheath, so it has to be retrieved through surgical venotomy.27 The major disadvantage is the large lumen catheter, which has to be inserted through a venotomy through the femoral vein without a guidewire, and the catheter is difficult to manipulate because of its size and stiffness.

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    Dr. Kucher receives consultant fees from Straub Medical, Switzerland.

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