SCVIR - Case Club

Pulmonary Artery Thrombectomy and Thrombolysis

Justin R. Zack, MD and Michael Wholey, MD
Southampton Hospital, NY and
The University of Texas Health Science Center at San Antonio, TX

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Fig. 1. Pulmonary arteriogram reveals a large clot burden within the left pulmonary artery and minimal filling of the distal pulmonary branches.	Fig. 2. After TPA administration there is further improvement in branch filling of the left pulmonary artery.
Case Reference No. CC-1001-07 A 63 year old man presented to the hospital with shortness of breath. A CT angiogram of revealed a large pulmonary embolus and interventional radiology was consulted for IVC filter placement. Due to the large amount of thrombus burden and his respiratory distress, the need for ventilatory assistance was considered impending, as the patient was tiring. After consultation, pulmonary thrombectomy and/or thrombolysis were suggested. The patient was brought to angiography and a pulmonary arteriogram revealed a large amount of thrombus within the left pulmonary artery (Figure 1). A 90 cm guiding sheath was placed in the left pulmonary artery and 14 mg of TPA was instilled into the pulmonary artery through a diagnostic catheter. A Hydrolyzer Thrombectomy Catheter (Cordis) was activated within the thrombus and a number of antegrade and retrograde sweeps were made (Figure 2). A 7mm x 4cm angioplasty balloon was then inflated within the left main pulmonary artery to macerate the clot. An additional 6mg of TPA was then pulse sprayed into the thrombus. A pulmonary arteriogram at the termination of the procedure revealed improved filling of the pulmonary artery branches with a large burden of residual thrombus within the left pulmonary artery (Figure 3). An IVC filter was placed and at the end of the procedure the patient was less short of breath and noticeably more comfortable. The patient was markedly improved the next day and continued to make a good recovery over the remainder of his hospital stay.	Fig. 3. Completion left pulmonary arteriogram after thrombectomy and thrombolysis and balloon maceration demonstrates improved distal branch filling with a large amount of residual of clot.
Questions: What success have you had with pulmonary thrombectomy and what devices do you use? What bolus dosage of TPA would you consider using and would you continue it as an overnight infusion? Are your physicians aware that this is available and how often are you consulted? What complications particular to this procedure have you encountered?
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