Acute pulmonary embolism: endovascular therapy

Abstract

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Keywords: Pulmonary embolism (PE); interdisciplinary communication; mechanical thrombolysis; thrombolytic therapy.

Figure 1

CTA and echocardiogram demonstrating an enlarged right ventricle in a patient with submissive PE. (A) Axial slice CT in a patient with submassive PE with right ventricle measuring 5.1 cm and left ventricle measuring 2.9 cm. Interventricular septal straightening and filling defects within both lower lobe pulmonary arteries is also noted; (B) short axis view from an echocardiogram in another patient demonstrating marked right ventricular dilatation. CT, computed tomography; PE, pulmonary embolism.

Figure 2

Successful initiation of bilateral CDT. MIP coronal reconstructions of a contrast-enhanced chest CT demonstrating large occlusive thrombi (arrowheads) within the right interlobar (A) and left lower lobar (B) arteries; (C) bilateral 5-F 10 cm infusion catheters (UniFuse, AngioDynamics, Latham, NY, USA) were placed via a right internal-jugular approach and embedded within thrombi. The 10 cm infusion lengths, where multiple sideholes are present, are demarcated by radiopaque markers (arrowheads). The right-sided catheter is within the right interlobar artery, and the left-sided catheter is within the left lower lobar artery. CDT, catheter-directed thrombolysis; MIP, maximal intensity projection; CT, computed tomography.

Figure 3

A 52-year-old female with submassive bilateral PE. Initial right pulmonary angiogram demonstrates a large filling defect in the interlobar PA (A); fluoroscopic spot image of the Arrow-Trerotola device in the interlobar PA (B); follow-up pulmonary angiogram demonstrates decrease thrombus in the interlobar artery prior to lysis catheter placement (C). PE, pulmonary embolism; PA, pulmonary artery.

Figure 4

A 67-year-old male with massive PE resulting in PEA arrest underwent emergent thrombectomy with the Penumbra Indigo device and 4 mg of tPA into the right and left pulmonary arteries. The patient was extubated and discharged from the ICU within 48 hours. (A) DSA demonstrating thrombus in the right upper lobe PA; (B) Indigo device in the right upper lobe PA; (C) follow-up DSA demonstrates removal of the thrombus in the right upper lobe PA. PE, pulmonary embolism; ICU, intensive care unit; PEA, pulseless electrical activity; tPA, tissue plasminogen activator; DSA, digital subtraction angiography; PA, pulmonary artery.