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Objective
We report our experience with catheter-directed, ultrasound-assisted thrombolysis for acute pulmonary embolism (PE). We were particularly interested in the metrics to assess early success and the safety of this procedure in patients deemed to be “high-risk” for thrombolytic therapy.
Methods
A retrospective evaluation of patients who underwent catheter-directed pulmonary thrombolysis in our practice over 29 months is reported. There were sixty-two (62) patients considered_all of whom presented with acute PE as diagnosed by CTA. The ratio of the right ventricle to left ventricle diameter (RV:LV) was noted as were pre-procedure pulmonary artery pressures. Demographic data, significant medical history and procedure details were recorded. CT scans were reviewed and confirmatory RV:LV ratios were obtained. Standard thrombolysis protocol was followed (1 mg tPA/hour/catheter following an initial 2 mg bolus/catheter). MINITAB v17 was used for data analysis.
Results
62 patients had a CT diagnosis of acute PE and pulmonary hypertension (PAP>25 mm Hg). Twelve patients (19%) were deemed to have a “high risk” for bleeding. On CTA, the mean pre-therapy RVaxial:LVaxial ratio was 1.5±0.4. The mean pre-therapy PAP was 55.0±13.1 mm Hg. After 19.4±3.4 hours of thrombolysis, the mean post-therapy PAP was 35.0±10.7 mm Hg, with a pressure drop of 21.3±11.8 mm Hg (39% decrease). Three patients (5%) suffered bleeding complications_two gastrointestinal bleeds and one rectus sheath hematoma. One of the three complications occurred in the “high-risk” group (1/12) and the other two in the general population of patients (2/50) (Fisher’s exact test, p=0.488). Minor bleeding complications (n=11, 18%) included puncture site hematomas, ecchymosis and traumatic hematuria. Considering all bleeding complications, increasing RVaxial:LVaxial ratio was a predictor of a bleeding complication, independent of all risk factors (Likelihood ratio test, p=0.005).
Conclusion
Catheter-directed thrombolysis for acute PE effectively reduced mean PA pressure in patients with a dilated RV. As only three patients had notable bleeding complications, only one of whom was high-risk, we additionally conclude that this is a safe procedure. We encourage the use of catheter-directed, ultrasound-assisted pulmonary thrombolysis for the management of severe, acute pulmonary embolization with a dilated RV.
CONCLUSIONS: