Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis in the treatment of acute pulmonary embolism and lower extremity deep venous thrombosis: A novel one-stop endovascular strategy

Abstract

Objective This study was performed to evaluate the efficacy and feasibility of percutaneous mechanical thrombectomy (PMT) combined with catheter-directed thrombolysis (CDT) in patients with acute pulmonary embolism (APE) and lower extremity deep venous thrombosis (LEDVT). Methods In total, 20 consecutive patients with APE and LEDVT were prospectively selected for PMT combined with CDT. Mechanical thrombus fragmentation and aspiration using a pigtail rotation catheter followed by CDT was performed in each patient. Details regarding the patients' clinical presentation and outcome, pulmonary status parameters (pulmonary arterial pressure, partial pressure of oxygen in arterial blood, Miller score, thigh and calf circumference, and shock index), and lower extremity parameters (thrombus-lysis grade and Villalta scale score) were recorded. Results All 20 patients' clinical manifestations significantly improved. Both the clinical success rate and technical success rate were 100%. No major adverse events occurred during hospitalization. Four patients developed iliac vein compression syndrome and underwent stent implantation in the iliac vein. No pulmonary embolism recurred within 16.5±6.8 months of follow-up. Conclusions The combination of PMT and CDT is a safe and effective treatment for APE and LEDVT with good short- and intermediate-term clinical outcomes.

Keywords: Acute pulmonary embolism; catheter-directed thrombolysis; deep venous thrombosis; endovascular therapy; percutaneous mechanical thrombectomy; post-thrombotic syndrome; venous stenosis.

Figure 1.

Images from a 66-year-old man with acute pulmonary embolism and bilateral deep vein thrombosis. (a) Preoperative pulmonary angiography shows massive emboli in the upper and intermediate section of a left lobe artery (white arrow) and in the intermediate section of a right lobe artery (white arrow). The pulmonary arterial pressure was 52/22 (mean, 37) mmHg, and the Miller score was 18. (b) After initial catheter fragmentation of the right lobe artery via a 6-French pigtail catheter, the embolus dislodged and partially diminished. (c) A balloon catheter (Admiral Xtreme; INVATEC/Medtronic, Minneapolis, MN, USA) was placed and dilated through the embolus to crush the thrombus attached to the artery wall. (d and e) The same procedures were performed on the left side. (f) Post-thrombolysis angiogram shows considerable recanalization and improved perfusion after the therapy (red arrows) compared with the initial situation, although some thrombi remained in the branches of pulmonary artery. The post-treatment pulmonary arterial pressure was 28/8 (mean, 18) mmHg, and the Miller score was 9.

Figure 2.

Low extremity venogram images from the same patient as in Figure 1. (a) A typical picture of bilateral common femoral vein puncture for establishing pulmonary and lower extremity access for intervention via a 6-French vascular sheath. (b) Prograde venography via the ipsilateral dorsalis pedis vein confirmed the presence of a thrombus (white arrow) in the popliteal vein. (c) A balloon catheter (4–6 mm × 120 mm/130 cm; INVATEC/Medtronic) with a 120-mm treatment length was placed into the thrombus and predilated in the venous lumen. (d) A multi-side hole catheter (Unifuse; Angiodynamics, Latham, NY, USA) was then introduced across the heaviest part of the clot, and a urokinase spray infusion was started for initial standard catheter-directed thrombolysis. (e) Post-thrombolysis showed complete resolution of the thrombus after a 20-hour infusion (red arrow). (f) A final venogram was evaluated to verify that the vena cava filter (black arrow) was in a good position before all thrombolysis devices were withdrawn.

Figure 3.

Hemodynamic changes in the mean (a) pulmonary arterial pressure (PAP), (b) partial pressure of oxygen in arterial blood (PaO₂), (c) Miller score, (d) shock index, and (e) mean circumference of the thigh and calf. All hemodynamic parameters were significantly improved after the procedure. (f) Kaplan–Meier curve for the estimated adverse event-free and survival rates. Bars denote medians, boxes denote interquartile ranges, and whiskers denote ranges from maximum to minimum. *P<0.0001 versus baseline.