Feasibility and safety of catheter-directed thrombolysis via superficial cubital vein for the treatment of acute massive and submassive pulmonary embolism

Abstract

Introduction: Proximal venous approaches (femoral or jugular) for catheter-directed thrombolysis (CDT) of acute pulmonary embolism (PE) dominate in clinical practice.

Aim: We investigated the feasibility and safety of CDT in acute PE by using the superficial cubital venous approach.

Material and methods: All patients with acute PE received intravenous unfractionated heparin plus CDT. CDT included mechanical thrombus fragmentation and the local application of adjuvant thrombolytic therapy through the pigtail catheter - alteplase administered as 2.5 mg bolus in each main branch of the pulmonary artery plus adjuvant 25 mg for 12 h in the more severely affected branch of the pulmonary artery.

Results: Twenty-seven consecutive patients presenting with acute massive (high risk) PE (n = 10) or submassive (intermediate risk) PE (n = 17) were enrolled in the study. The mean age of the enrolled cohort was 60.6 (14.1) years and most patients were female (n = 14, 52%). The procedural success of CDT application through the cubital vein was achieved in all patients. After the procedure, the systolic pulmonary artery pressure decreased from 61.4 (18.3) to 35.8 (12.3) mm Hg (p < 0.001) while the mean pulmonary artery pressure decreased from 35.7 (10.8) to 21.1 (6.5) mm Hg (p < 0.001). Similarly, the mean arterial pressure increased from 81.9 (12.8) to 89.0 (10.3) mm Hg (p = 0.031). Miller angiographic obstruction score and Miller index decreased significantly after the CDT intervention (p < 0.001). There were no deaths, major bleeding events, or hemorrhagic strokes.

Conclusions: CDT by using the cubital approach is a simple, safe, and feasible treatment option for PE. This approach was associated with significant improvement in hemodynamic parameters without fatal outcomes or major periprocedural complications.

Keywords: alteplase; catheter-directed thrombolysis; pharmacoinvasive approach; pulmonary embolism; thrombus fragmentation.

Figure 1

A, B – Pulmonary angiogram of pulmonary arteries prior to catheter-directed thrombolysis (CDT), C, D – 12 h after CDT showing the almost complete resolution of the thrombus and recanalization of the pulmonary arterial blood flow

Figure 2

Before-after graph showing pre-CDT versus post-CDT values of pulmonary artery systolic pressure (PASP), mean pulmonary artery pressure (mPAP), and mean arterial pressure (MAP) among all enrolled patients