Case Reference No. CC-1097-05 The patient is a 39-year-old obese woman who presented with exertional dyspnea. Her past medical history included Hodgkin's lymphoma and depression with prior suicide attempts. Her physical examination and chest film were unremarkable. A CT scan of the chest revealed large bilateral pulmonary emboli. The referring clinical service was reluctant to treat the patient with long-term anticoagulation given her prior suicide attempts and a history of poor compliance. As a result, our service was consulted for possible selective pulmonary artery thrombolysis. The initial pulmonary arteriogram was performed from a right basilic vein approach utilizing a Willie-3 catheter (Cordis, Inc., Miami, FL). This approach was chosen because it was believed that it would help the patient better tolerate slow infusion lytic therapy. The initial pulmonary artery pressures were 82/43 mm Hg, with massive bilateral pulmonary emboli, shown on selective injections (Fig. 1). The diagnostic catheter was left in place with the right arm immobilized, and the patient was transferred to the intensive care unit for observation during thrombolytic infusion. Urokinase was infused at a rate of 250,000 U per hour for a total of 36 hours. Arteriography was performed at 12, 24, and 36 hours, and the catheter was repositioned between the left and right pulmonary arteries as lysis progressed. On the final arteriogram, there was near total resolution of emboli (Fig. 2). The final pulmonary arterial pressures were 20/8 mm Hg.		Fig. 1. Digital pulmonary arteriogram of the left pulmonary arterial tree. Multiple pulmonary emboli are demonstrated. The right pulmonary artery showed similar findings. Fig. 2. Digital subtraction left pulmonary arteriogram. No residual pulmonary emboli are identified. The right pulmonary artery showed similar findings.
Questions 1)What are the indications for selective intraarterial or systemic thrombolysis for pulmonary emboli? Is this patient a candidate despite having only modest clinical signs of cardiopulmonary compromise? 2) At this time, the literature does not support the use of selective intraarterial lytic therapy over systemic infusion. What is the experience of the case club participants? Is there ever a role for selective lytic therapy? Should this subject be revisited? 3) Has anyone used lytic agents other than urokinase in this setting? 4) Has anyone had experience (positive or negative) with mechanical thrombectomy devices in this setting?