Protocol for interventional treatment of massive and submassive pulmonary embolism by 12-hour mechanical and pharmacological thrombolysis during 72-hours hospitalisation

    Authors

    Keywords

    pulmonary embolism, mechanical fragmentation, local pharmacological thrombolysis

    DOI

    https://doi.org/10.15836/ccar2016.460

    Full Text

    1. Upon clinical suspicion of pulmonary embolism, bolus dose of heparin is administered, and diagnostic process including urgent echocardiogram, hsTnT, NT-proBNP and MSCT pulmonary angiogram, procoagulant factors begun. The degree of severity of pulmonary embolism (massive, submassive), as well as contraindications to thrombolytic therapy, is assessed, the interventional team prompted, and the patient transported to invasive laboratory (in severe clinical condition, urgently, on the basis of clinical assessment and prior to MSCT angiography), puncture of the cubital vein being done in the Coronary Care Unit. (1, 2) 2. In the intervention lab, 6F sheath is introduced cubitally. Under fluoroscopic guidance, 5F angiographic catheter (Multipurpose or JR 4) is placed in the main pulmonary artery, and exchanged for 5F pigtail catheter. The pulmonary artery pressure is registered, and pulmonary angiography done, followed by mechanical fragmentation of emboli by rotating of the catheter. The goal is to reduce the degree of obstruction caused by thrombi in the trunk and main branches of the pulmonary artery, and resolve the immediate threat to life. Bolus of 2.5 mg/min of alteplase is administered in one of main branches of pulmonary artery. If clinically and angiographically indicated, procedure should be repeated in the other main branch. Intrapulmonary thrombolytic therapy is continued by infusion of 25 mg alteplase over the next 12 hours, followed by standard heparin infusion (starting at 1000 i.e. per hour). Control angiography and of pulmonary pressure measurement is performed as soon as interventional laboratory is available, and catheter and sheath removed. 3. Treatment is continued with subcutaneous low molecular weight heparin (LMWH), at a dose adjusted to body weight. 4. LMWH is replaced with the oral anticoagulation therapy, optimal NOAC (rivaroxaban, dabigatran, apixaban) and continued for 6-12 months. 5. Follow-up is performed at 6 months (ECG, echocardiogram, DLCO).

    Literature

    1. Engelberger RP, Kucher N. Catheter-based reperfusion treatment of pulmonary embolism. Circulation. 2011;124(19):2139–44. https://doi.org/10.1161/CIRCULATIONAHA.111.023689
    2. Schmitz-Rode T, Janssens U, Duda SH, Erley CM, Günther RW. Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter. J Am Coll Cardiol. 2000;36(2):375–80. https://doi.org/10.1016/S0735-1097(00)00734-8
    Cardiologia Croatica
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    Protocol for interventional treatment of massive and submassive pulmonary embolism by 12-hour mechanical and pharmacological thrombolysis during 72-hours hospitalisation

    Extended Abstract
    Issue10-11
    Published
    Pages460
    PDF via DOIhttps://doi.org/10.15836/ccar2016.460
    pulmonary embolism
    mechanical fragmentation
    local pharmacological thrombolysis

    Authors

    Lovel GiunioORCIDUniversity of Split School of Medicine, University Hospital Centre Split, Split, Croatia
    Anteo Bradarić*ORCIDUniversity of Split School of Medicine, University Hospital Centre Split, Split, Croatia
    Mislav LozoORCIDUniversity of Split School of Medicine, University Hospital Centre Split, Split, Croatia
    Jakša ZanchiORCIDUniversity of Split School of Medicine, University Hospital Centre Split, Split, Croatia

    *Correspondence email: anteo.bradaric@gmail.com

    Full Text

    1. Upon clinical suspicion of pulmonary embolism, bolus dose of heparin is administered, and diagnostic process including urgent echocardiogram, hsTnT, NT-proBNP and MSCT pulmonary angiogram, procoagulant factors begun. The degree of severity of pulmonary embolism (massive, submassive), as well as contraindications to thrombolytic therapy, is assessed, the interventional team prompted, and the patient transported to invasive laboratory (in severe clinical condition, urgently, on the basis of clinical assessment and prior to MSCT angiography), puncture of the cubital vein being done in the Coronary Care Unit. (1, 2)
    1. In the intervention lab, 6F sheath is introduced cubitally. Under fluoroscopic guidance, 5F angiographic catheter (Multipurpose or JR 4) is placed in the main pulmonary artery, and exchanged for 5F pigtail catheter. The pulmonary artery pressure is registered, and pulmonary angiography done, followed by mechanical fragmentation of emboli by rotating of the catheter. The goal is to reduce the degree of obstruction caused by thrombi in the trunk and main branches of the pulmonary artery, and resolve the immediate threat to life. Bolus of 2.5 mg/min of alteplase is administered in one of main branches of pulmonary artery. If clinically and angiographically indicated, procedure should be repeated in the other main branch. Intrapulmonary thrombolytic therapy is continued by infusion of 25 mg alteplase over the next 12 hours, followed by standard heparin infusion (starting at 1000 i.e. per hour). Control angiography and of pulmonary pressure measurement is performed as soon as interventional laboratory is available, and catheter and sheath removed.
    1. Treatment is continued with subcutaneous low molecular weight heparin (LMWH), at a dose adjusted to body weight.
    1. LMWH is replaced with the oral anticoagulation therapy, optimal NOAC (rivaroxaban, dabigatran, apixaban) and continued for 6-12 months.
    1. Follow-up is performed at 6 months (ECG, echocardiogram, DLCO).

    Literature

    1. 1.
      Engelberger RP, Kucher N. Catheter-based reperfusion treatment of pulmonary embolism. Circulation. 2011;124(19):2139–44.DOI
    2. 2.
      Schmitz-Rode T, Janssens U, Duda SH, Erley CM, Günther RW. Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter. J Am Coll Cardiol. 2000;36(2):375–80.DOI