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Review
. 2018 Jun;35(2):122-128.
doi: 10.1055/s-0038-1642041. Epub 2018 Jun 4.

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

Matthew A Chiarello  1 , Akhilesh K Sista  2
Affiliations
Review

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

Matthew A Chiarello et al. Semin Intervent Radiol. 2018 Jun.

Abstract

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality in the United States. PE associated with right ventricular strain, termed submassive or intermediate-risk PE, is associated with an increased rate of clinical deterioration and short-term mortality. Trials have demonstrated systemic thrombolytics may improve patient outcomes, but they carry a risk of major hemorrhage. Catheter-directed thrombolysis (CDT) may offer similar efficacy to and a lower risk of catastrophic hemorrhage than systemic thrombolysis. Three prospective trials have evaluated CDT for submassive PE; ULTIMA, SEATTLE II, and PERFECT. These trials provide evidence that CDT may improve radiographic efficacy endpoints in submassive PE with acceptable rates of major hemorrhage. However, the lack of clinical endpoints, long-term follow-up, and adequate sample size limit their generalizability. Future trials should be adequately powered and controlled so that the short- and long-term effectiveness and safety of CDT can be definitively determined.

Keywords: Catheter-Directed Thrombolysis; interventional radiology; submassive pulmonary embolism; ultrasound-assisted thrombolysis.

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Figures

Fig. 1
Fig. 1
Examples of catheter options for pulmonary artery access. From left to right: Nyman, Grollman, standard straight pigtail flush catheter, balloon tipped occlusion catheter with distal side holes. (Reprinted with permission from Biam. 24 )
Fig. 2
Fig. 2
Case background information: a 40-year-old man with history of systemic lupus erythematosus and morbid obesity who underwent laparoscopic sleeve gastrectomy 4 weeks prior to presentation of acute shortness of breath. ( a ) Coronal slice of initial CT pulmonary angiogram demonstrating large filling defect in the right main pulmonary artery (arrow). ( b ) Axial slice from initial CT pulmonary angiogram demonstrating dilated right ventricle and straightening of the interventricular septum. ( c ) Intraprocedure fluoroscopic image demonstrating bilateral pulmonary arterial catheters, with catheter tips in the right and left pulmonary arteries (arrows). ( d ) Coronal slice of postprocedure CT pulmonary angiogram demonstrating near-complete resolution of the pulmonary embolism (arrow). ( e ). Axial slice of postprocedure CT pulmonary angiogram demonstrating resolution of right ventricular dilatation and convexity of the interventricular septum.
Fig. 3
Fig. 3
Results from PERFECT, SEATTLE II, and ULTIMA trials demonstrating similar mean systolic pulmonary artery pressures, at baseline and after intervention with CDT. (Reprinted with permission from Kuo et al. 39 )
See this image and copyright information in PMC

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