Catheter-Directed Thrombolytic Therapy for Massive and Submassive Pulmonary Embolus: A Community Hospital Experience

Abstract

Introduction: Pulmonary embolism (PE) is responsible for 200,000deaths in the United States annually. Catheter directed thrombolytic therapy(CDTT) is reserved for massive and submassive PE, and rarely practicedoutside of tertiary care university settings. Here we present a series of nineconsecutive patients with massive (on pressors with hemodynamic instability)or submassive PE (echocardiograms showing pulmonary artery pressure> 70 mm Hg, right heart strain, and continued need for supplementaloxygen ) treated with CDTT in a community vascular surgery practice.Methods: Four patients were treated for massive PE and five weretreated for submassive PE. All patients had been treated in intensive careunits with systemic anticoagulation and significant supplemental oxygenrequirement for as long as 5 days prior to being referred for lytic therapy.Upon referral, patients were treated with CDTT with powerpulse infusion of10 to 15 mg of Alteplase into the left, right, and main pulmonary arteries.The decision to use mechanical thrombectomy was made at the time ofprocedure based on the patient's clinical condition.Results: All nine patients were treated in a single setting. The mean agewas 54.8 ± 11.4 years, with 1 male and 8 females. The end point oftreatment was weaning off pressors and/or decreased oxygen requirement.This was achieved in all nine patients (100% procedural success rate). Onepatient developed hemodynamically significant heart block with each attemptat powerpulse delivery, but was successfully treated with forcefulinjection through a running EKOS catheter. All patients were off supplementaloxygen within 24 hours of the procedure. There were no bleedingevents in any patient. One patient expired 14 hours after the procedure with (Figure presented) a suspected paradoxical embolus to the intestines (overall mortality 11%).The eight surviving patients were discharged to home within 48 hours of theintervention and had normal PA pressures without any evidence of rightheart strain on echocardiogram performed one month after their CDTTprocedure.Conclusions: Massive or submassive PE can be treated safely withCDTT in a community hospital setting. This can reduce the need for lengthyICU stays, shorten overall hospital length of stay, eliminate the need forhome oxygen therapy, and restore right heart function with an acceptablemortality rate. Development of institutional CDTT expertise in conjunctionwith protocols to administer this therapy early in the course of massive andsubmassive PE may yield significant mortality and morbidity benefits incommunity hospitals.