Background: The optimal use of pharmaco-mechanical therapy is not clear in the management of the acute massive pulmonary thromboembolism.
Methods: A 30-year-old postpartum female presented with acute massive pulmonary embolism and was managed with catheter mediated thrombus aspiration and fragmentation after the standard intravenous thrombolysis had failed. Thrombus was aspirated by 7F Mullins sheath with 50cc aspiration syringe and was fragmented by TYSHAK II PTV balloon. This was followed by catheter directed thrombolysis.
Results: Intravenous thrombolysis was only partially successful whereas catheter mediated thrombus aspiration and fragmentation followed by catheter directed thrombolysis resulted in hemodynamic stabilization and early discharge from the hospital.
Conclusion: Pharmaco-mechanical therapy is an effective therapy of acute massive pulmonary embolism and may be beneficial over the standard systemic thrombolysis

Neeraj Pandit

Ranjit Nath

Sandeep Goel

Indian Heart Journal

PubMed

AbstractBackgroundThe optimal use of pharmaco-mechanical therapy is not clear in the management of the acute massive pulmonary thromboembolism.MethodsA 30-year-old postpartum female presented with acute massive pulmonary embolism and was managed with catheter mediated thrombus aspiration and fragmentation after the standard intravenous thrombolysis had failed. Thrombus was aspirated by 7F Mullins sheath with 50cc aspiration syringe and was fragmented by TYSHAK II PTV balloon. This was followed by catheter directed thrombolysis.ResultsIntravenous thrombolysis was only partially successful whereas catheter mediated thrombus aspiration and fragmentation followed by catheter directed thrombolysis resulted in hemodynamic stabilization and early discharge from the hospital.ConclusionPharmaco-mechanical therapy is an effective therapy of acute massive pulmonary embolism and may be beneficial over the standard systemic thrombolysis

Goel, Sandeep

Nath, Ranjit

Pandit, Neeraj

Elsevier - Publisher Connector 

Pharmaco – Mechanical management of acute massive pulmonary embolism in a postpartum female 

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Pharmaco – Mechanical management of acute massive pulmonary embolism in a postpartum female

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i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 3 7 8e3 8 1Available online at wScienceDirect
journal homepage: www.elsevier .com/locate / ih jCase ReportPharmaco e Mechanical management of acute
massive pulmonary embolism in a postpartum
femaleSandeep Goel a,*, Ranjit Nath b, Neeraj Pandit c
aSenior Resident, Department of Cardiology, Dr RML Hospital and PGIMER, Baba Kharak Singh Marg,
New Delhi 110001, India
bAssociate Professor, Department of Cardiology, Dr RML Hospital and PGIMER, Baba Kharak Singh Marg,
New Delhi 110001, India
cProfessor, Department of Cardiology, Dr RML Hospital and PGIMER, Baba Kharak Singh Marg,
New Delhi 110001, Indiaa r t i c l e i n f o
Article history:
Received 19 April 2013
Accepted 5 December 2013
Available online 30 December 2013
Keywords:
Streptokinase (STK)
Pharmaco-mechanical therapy
(PMT)
Catheter directed thrombolysis
(CDT)* Corresponding author. Tel.: þ91 9968004433
E-mail address: dr_sandeepgoel@yahoo.c
0019-4832/$ e see front matter Copyright ª
http://dx.doi.org/10.1016/j.ihj.2013.12.029a b s t r a c t
Background: The optimal use of pharmaco-mechanical therapy is not clear in the man-
agement of the acute massive pulmonary thromboembolism.
Methods: A 30-year-old postpartum female presented with acute massive pulmonary em-
bolism and was managed with catheter mediated thrombus aspiration and fragmentation
after the standard intravenous thrombolysis had failed. Thrombus was aspirated by 7F
Mullins sheath with 50cc aspiration syringe and was fragmented by TYSHAK II PTV
balloon. This was followed by catheter directed thrombolysis.
Results: Intravenous thrombolysis was only partially successful whereas catheter mediated
thrombus aspiration and fragmentation followed by catheter directed thrombolysis
resulted in hemodynamic stabilization and early discharge from the hospital.
Conclusion: Pharmaco-mechanical therapy is an effective therapy of acute massive pul-
monary embolism and may be beneficial over the standard systemic thrombolysis.
Copyright ª 2013, Cardiological Society of India. All rights reserved.1. Introduction
Acutemassive pulmonary embolism is often under-diagnosed
due to low suspicion by the clinicians. When it is diagnosed,
its management remains uncertain. In particular, the optimal
use of advanced therapies, including thrombolysis and
catheter-based therapies. Here we present one such case of a
young female with acute massive pulmonary embolism who.
om (S. Goel).
2013, Cardiological Sociewas successfully managed with Pharmaco-mechanical
therapy (PMT) after the systemic thrombolysis was only
partially successful.2. Case
A 30-year-old female with history of normal delivery one
month ago, presented with complaints of shortness of breath,ty of India. All rights reserved.
i n d i a n h e a r t j o u rn a l 6 6 ( 2 0 1 4 ) 3 7 8e3 8 1 379dry cough and palpitations for the past 2 days. On examina-
tion the patient had pulse rate of 140/min, respiratory rate of
40/min, blood pressure (BP) of 80/50 mmHg. Chest had bilat-
eral wheeze and cardiac examination was normal. Routine
blood investigations were normal and EKG had sinus tachy-
cardia, S1Q3T3 pattern, right axis deviation with qR and ST
elevationwith Twave inversion in V1, D-DIMERwas>2000 mg/
L. CT-angiography was done that revealed large filling defects
in bilateral pulmonary arteries with distended proximal pul-
monary arteries, suggestive of acute occlusion. 2D echocar-
diography was done as shown in Fig. 1C. Based on clinical
history, physical examination and investigations, a diagnosis
of acute massive pulmonary embolism was made.
The patient was managed with O2 inhalation by nasal
prongs, dopamine at 10 mg/kg/ml, and intravenous (IV) fluids
at 100 ml/h. Patient was thrombolysed with streptokinase
(STK), which was administered as an IV bolus of 0.25 million
units and followed by an infusion of 0.1 million unit/hr. After
24 h the patient’s blood pressure improved to 90/64 mmHg
without inotropes but she was not maintaining saturation
without oxygen (SO2 88% without O2). 2D Echocardiography
(Fig. 1D) and CT angiography (Fig. 1A) were repeated. There
was no definite success of the thrombolysis.
Since clinically the patient had shown only partial
improvement, it was decided to perform catheter mediatedFig. 1 e Fig. 1C; 2D Echocardiography at presentation showing
and left pulmonary artery (LPA) (red arrow head). Post systemic
Echocardiography (Fig. 1D) shows main pulmonary artery (MPA
thrombus which gets cleared (Fig. 1B, CT angiography and 1E, 2
red arrow.thrombus aspiration and fragmentation. The patient was not
able to hold the breath, as is seen with most of the patients of
massive pulmonary embolism, so DSA was not possible. Pul-
monary angiography was done as shown in Fig. 2. The 0.035
Amplatz extra stiff guide wire (Cook Inc., Bloomington, IN)
was passed across the thrombus in the left pulmonary artery
(LPA). The thrombus was aspirated repeatedly with the 7F
Mullins sheath (Medtronic, Minneapolis, MN) with 50cc aspi-
ration syringe. TYSHAK II PTV balloon (NuMED Inc., Hopkin-
ton, New York, U.S.A.) of different sizes were taken over the
wire and the clot was fragmented by inflating the balloon
repeatedly at very low pressure within the thrombus.
Thrombus aspiration was done after each balloon inflation.
The balloon was exchanged with the Goodale Lubin catheter
(Medtronic Vascular, Inc.) and its distal end was left
embedded in the thrombus and catheter directed STK at
100,000 IU per hour was given so that the fragmented
thrombus could be lysed further. During catheter directed
thrombolysis (CDT) 2D Echocardiography was repeated every
6 h, to decide the duration of infusion. After 24 h, CDT was
stopped and the Goodale Lubin catheter was removed. Post
PharmacoMechanical Therapy (PMT), CT angiography (Fig. 1B)
and 2D Echocardiography (Fig. 1E) were done. The patient was
discharged on the 5th day of hospital admission, on oral
warfarin, with BP of 110/80 without inotropes, SpO2 of 100% atthrombus in right pulmonary artery (RPA) (red arrow head)
thrombolysis CT angiography (Fig. 1A) and 2D
), RPA are clear but LPA; red arrow, still contain large
D Echocardiography) Post catheter directed thrombolysis,
Fig. 2 e Post thrombolysis pulmonary angiography. Fig. 2A shows clearance of RPA thrombus Fig. 2B shows LPA with large
thrombus with faint visualization of the branches. Fig. 2C shows thrombus fragmentation by balloon dilatation in LPA.
Fig. 2D shows clot fragmentation and better visualization of the LPA branches.
i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 3 7 8e3 8 1380room air, pulse rate of 86/min, RR 16/min and without any
effort limiting symptom.3. Discussion
This is a case of acute massive pulmonary embolism as
defined by acc guidelines 2011.1 The patient had several poor
prognostic markers2e5 like hypotension, low SO2 and S1Q3T3
with sinus tachycardia, qR in V1 on ECG and RV dysfunction
on 2D Echocardiography. S. Wan et al had shown that
thrombolytic therapy was beneficial over heparin alone in
massive venous thromboembolism (VTE) with significant
reduction in recurrent PE or death from 19.0% with heparin
alone to 9.4% with fibrinolysis (odds ratio 0.45, 95% CI
0.22e0.90).6 As our patient was young so the bleeding risk was
low. Considering the benefits and low bleeding risk, the
fibrinolysis was considered as an appropriate therapy.
Various thrombolytic agents have been used in multiple trials
but only 6 randomized trials comparing any two fibrinolytics
have been done.7 Meneveau et al8 compared streptokinase
250,000 IU IV bolus followed by 100,000 IU per hour infusion
for 12 h with rtPA and USET phase 29 compared same dose of
streptokinase with urokinase and they concluded that
streptokinase produced slow improvement of pulmonaryhemodynamics but in the end, the result was similar to rtPA
at 12 h8 and urokinase on 5th day.9 Considering the cost
difference and almost equal benefits, streptokinase
250,000 IU IV bolus followed by 100,000 IU/hr IV infusion was
given. Using hybrid therapy that includes both catheter-
based clot fragmentation and local thrombolysis vs sys-
temic thrombolysis may be more beneficial with higher suc-
cess rates.10 Currently, no randomized trial between the two
approaches is available and till the time any such trial is done
catheter mediated hybrid therapy will be reserved only for
thrombolysis contraindications and failure.5 Out of different
catheter mediated therapies11 (1) thrombus fragmentation, (2)
rheolytic thrombectomy, (3) suction thrombectomy, and (4)
rotational thrombectomy, clot fragmentation and thrombus
aspiration are simple procedures as they do not require any
specialized instruments and can be done easily with the use
of balloons or pig tail catheters easily available in any cath-
lab. The main disadvantage12 is the hemodynamic deterio-
ration by the distal embolization of the non obstructive
embolus. This can be reduced by using the adjuvant catheter
directed thrombolysis post fragmentation.10,13 The local
catheter directed therapy is highly successful as compared to
systemic thrombolysis and it is only a matter of time when it
will be a therapy of choice in a setup where a cath lab is
available.
i n d i a n h e a r t j o u rn a l 6 6 ( 2 0 1 4 ) 3 7 8e3 8 1 3814. Conclusion
Pharmaco-mechanical therapy is an effective therapy of acute
massive pulmonary embolism and may be beneficial over the
standard systemic thrombolysis. A randomized trial is
required to establish its role firmly in the management vis a
vis systemic thrombolysis. However, If done early, it may be
life saving and may result in rapid recovery.Conflicts of interest
All authors have none to declare.r e f e r e n c e s
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