Fragmentation of Massive Pulmonary Embolism Using a Pigtail Rotation Catheter: Results

15 Jul
2014

Fragmentation of Massive Pulmonary Embolism Using a Pigtail Rotation Catheter: ResultsFragmentation success was defined as a recanalization o( occluded area of s25%. The 48-h treatment success (including thrombolysis, if performed) was defined as circulatory stabilization 48 h after fragmentation with a shock index < 1, a mean pulmonary arterial pressure < 25 mm Hg, and a systemic arterial BP returned to normal values.
Overall treatment success was defined as the final clinical outcome of the patient (at the day of discharge from hospital), under consideration of all adverse events, which happened before or after fragmentation.
The paired Wilcoxon signed rank test was used for statistical analysis of prefragmentation and postfragmentation and 48-h follow-up data.
Results
One patient was not included in the study due to a large embolus-in-transit in the right side of the heart detected by transesophageal echocardiography. In 10 patients, catheter fragmentation of pulmonary emboli was performed (Fig 2). The right pulmonary artery was treated in four cases, the left pulmonary artery in five cases, in one patient both sides were treated.
Seven of the 10 patients were receiving mechanical ventilation with a high fraction of inspired oxygen (0.8 ± 0.15) prior to fragmentation therapy (Table 1). Unstable hemodynamics required positive inotropic support with medium- to high-dose catecholamines in this group. Three patients underwent cardiopulmonary resuscitation (Table 1). In one patient (No. 3), a shock index > 1 at the time of inclusion decreased below the level of 1 immediately prior to fragmentation, due to inotropic support.
The study results are given in Tables 2-5.
Average shock index decreased significantly prefragmentation to postfragmentation from 1.52 to 1.22 (p = 0.03, Table 2) and to 0.81 48 h later (p < 0.001). The increase in systolic and diastolic systemic BP prefragmentation to postfragmentation was just beyond the level of significance (p = 0.06). Further development within the 48-h follow-up was clearly insignificant.

Figure 2. A .36-year-old male patient with traumatic fractures of the first cervical vertebra, right upper and lower leg, and thrombosis ol the right femoral vein. Top left: Prefragmentation complete occlusion of the left pulmonary artery. Top right: pigtail rotation catheter in place, from left femoral approach (right femoral thrombi, jugular approach not possible, because patient was wearing a “stiff-neck” bandage). Bottom left: after embolus fragmentation: partial recanalization and intraluminal fragments (arrows). Bottom right: final control angiography 3 days later (central venous digital subtraction angiography) after additional thrombolysis with 70 mg ol plasminogen activator.

Figure 2. A .36-year-old male patient with traumatic fractures of the first cervical vertebra, right upper and lower leg, and thrombosis ol the right femoral vein. Top left: Prefragmentation complete occlusion of the left pulmonary artery. Top right: pigtail rotation catheter in place, from left femoral approach (right femoral thrombi, jugular approach not possible, because patient was wearing a “stiff-neck” bandage). Bottom left: after embolus fragmentation: partial recanalization and intraluminal fragments (arrows). Bottom right: final control angiography 3 days later (central venous digital subtraction angiography) after additional thrombolysis with 70 mg ol plasminogen activator.

Table 2—Circulatory Data

Patient No.Shock IndexPulmonary Artery BP, mm Hg
(Heart Rate/Systolic Systemic BP)SystolicMeanDiastolic
BeforeAfter48 h ‘BeforeAfter48 h’BeforeAfter48 h’BeforeAfter48 h’
11.201.370.77505049363631313024
21.050.980.58424522293319251818
30.940.980.66554543363029272214
41.401.270.8344321629201122168
51.560.760.4269661833321112137
61.201.050.752828
71.081.000.92574444353329222022
81.781.000.5755482434321121184
92.822.02*4743*3230*2718f
102.141.761.80484931404024373416
Mean ± SD1.52 ± 0.561.22 ± 0.380.81 ± 0.3852 ± 847 ±831 ± 1233 ±431 ±521 ± 825 ± 721 ±614 ± 7

Table 3—Fragmentation Procedure and Angiographic Outcome Data

PatientNo.Approach* Jug FemProcedure Time, minReal Fragmentation Time, minTechnical Problems With Cathete:Angiographic Severity Index (According to Walsh et al) Prefragmentation/PostfragmentationRecanalization in Percent of Occluded Area
r RightLeftRightLeft
1Rjug6015No7/3 f657
2R jug60301. set:j78/5 f38
R jUg2. set: no
3Rjug4025Mismatch^9/8 f6(11)
4L fem3515No29/6 f33
5R fem84No8/6 f225
6R fem5515Mismatch §9/8 f6(11)
7L jug5015No7/5 f8/6 f2925
8R fem1510No37/4 f43
9R fem2010No68/5 f38
10R fem7035Mismatch^9/8 f(11)
Mean ± SD41 ± 2017 ± 929.2 ± 14.0% |

Table 4—Medical Therapy Data

PatientNo.Heparin Dose, IU, Initial + Maintenance/dContraindication to Thrombolysis TreatmentThrombolytic Agent UsedThrombolysis Total Dose, mgTime Relation to FragmentationMode of Application
115,000 + 25,000Nort-PA10055 min beforeIV
25,000 + 25,000Relative: recent abdominal surgery (5 d ago)rt-PA4013 h afterIV
3_*Relative: fracturesrt-P A/urokinase60/+170,000 U/h1 d before/3 h before (3 d)IV
4_*Relative: fracturesrt-PA70FollowingfragmentationIV
50 + 24,000Nort-PA605 min afterCatheter
63,000 + 19,200fNo (surgery 2 wk ago)rt-PA22.590 min afterCatheter
77,500 + 21,600Absolute: cranial surgery 1 d before
80 + 25,000Absolute: fresh cranial trauma
95,000 + 0Relative: cranial surgery (10 d ago)rt-PA10010 min beforeIV
105,000 + 25,000Relative: infarction medial cerebral arteryrt-PA50FollowingfragmentationCatheter

Table 5—Clinical Outcome Data

Preexisting
Patient No.Cardiopulmonary/ eurologic DeficitsDeficits Acquired Within 48-h-IntervalCirculator)/ Restitution at 48 h*Deficits Acquired After 48-h IntervalFinal Restitution/ Clinical Outcome
1Pulmonary hypertensionComplete, (exceptpulmonary hypertension)Sepsis + multiorgan failure (14 d after fragmentation)!Death
2CompleteComplete
3Incomplete, elevated pulmonary pressure, thrombolysis continuedComplete
4CompleteComplete
5CompleteComplete
6Right bundle blockCompleteComplete
7Brain death (cardiac arrest of unknown duration)Incomplete, circulation stable, but elevated pulmonary pressureCirculation stable organ donor
8CompleteComplete
9Right heart insufficiencyDeath (1 h postfragmentation)DiedDeath
10Left hemiparesisIncomplete, shock index elevated, catecholamines continuedComplete (except neurologic deficit)
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