Percutaneous Pulmonary Embolus Mechanical Thrombectomy

Study Questions:

What is the efficacy of percutaneous mechanical thrombectomy for pulmonary embolism (PE)?

Methods:

A 66-year-old African-American woman with no significant past medical history presented with a 2-day history of worsening exertional dyspnea with minimal activity. Pulmonary embolus (PE) was suspected and computed tomography (CT) of the chest revealed extensive, acute bilateral PE with significant clot burden in the right main pulmonary artery (PA). There was evidence of right heart strain with right ventricular (RV) dilatation. Transthoracic echocardiography (TTE) confirmed moderate RV dilatation and systolic dysfunction. Her estimated RV systolic pressure (RVSP) was 71 mm Hg. Given her hemodynamic stability and based on the patient’s own preference, she was started on intravenous heparin and conservative management. Over the next 72 hours, her symptoms did not improve and she perceived dyspnea at rest. Repeat TTE revealed persistent RV dilatation and systolic dysfunction with an estimated RVSP of 90 mm Hg. Due to persistent significant symptoms and severe pulmonary hypertension, she underwent percutaneous aspiration/mechanical pulmonary embolectomy from her right PA and segmental (middle and lower) arteries.

Results:

Her mean PA pressure immediately post-embolectomy was 33 mm Hg. She had a noticeable improvement in her dyspnea with improvement in her oxygen saturation. Twenty-hour post-procedure TTE revealed a decrease in RV dilatation to mild from moderate, improvement in RV dysfunction to mild from moderate, and an estimated RVSP of 45 mm Hg from 90 mm Hg. She was able to ambulate with minimal dyspnea. She was switched to oral apixaban for PE management and discharged 24 hours post-thrombectomy.

Conclusions:

Significant clinical improvement was noted in this case of extensive, acute bilateral PE with mechanical thrombectomy.

Perspective:

The current 2016 American College of Chest Physicians Guideline on Antithrombotic Therapy for VTE Disease recommends as Grade 2C that in patients with acute PE associated with hypotension and who have (i) a high bleeding risk, (ii) failed systemic thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (e.g., within hours), if appropriate expertise and resources are available, catheter-assisted thrombus removal may be indicated. Additional prospective studies are indicated to define the role of percutaneous mechanical thrombectomy for PE.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Cardiac Surgery and Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Vascular Medicine, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Blood Pressure, Dilatation, Dyspnea, Echocardiography, Embolectomy, Fibrinolytic Agents, Heparin, Hypertension, Pulmonary, Hypotension, Pulmonary Embolism, Thrombectomy, Thrombosis, Tomography, Tomography, X-Ray Computed, Ventricular Dysfunction, Right


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