Mechanical and Enzymatic Thrombolysis for Massive Pulmonary Embolism

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PURPOSE

To assess the efficacy and safety of mechanical fragmentation combined with intrapulmonary thrombolysis in massive pulmonary thromboembolism (PTE) with hemodynamic impairment.

MATERIALS AND METHODS

Fifty-nine patients diagnosed with massive PTE with hemodynamic impact were treated. The initial clinical symptoms were shock in 23 patients (38.9%), syncope in eight (13.5%), and dyspnea at rest in 28 (47.4%). Mean 02 saturation was 67.8%. Mean pulmonary artery pressure (PAP) was 42.1 mm Hg. During fragmentation, thrombolysis was administered in the form of a urokinase bolus of 200,000–500,000 U in 57 patients and 20 mg of recombinant tissue plasminogen activator (rt-PA) in two patients. The mean urokinase dose used was 2,500,000 IU, whereas the total dose of rt-PA was 100 mg. Heparin sodium infusion was performed to reach activated partial thromboplastin time ratios of 2. The follow-up consisted of clinical assessment, pulmonary scintigraphy, and echocardiography. The patients received treatment with dicoumarin for 6 months after the procedure.

RESULTS

Clinical improvement was seen in 56 patients (94%). Three patients died. The mean PAP after the treatment was 21.8 mm Hg. The mean posttreatment Miller index was 0.35. Technical success was achieved in all cases and clinical symptoms improved in all cases except those in which the patients died. Pulmonary scintigraphy showed improved perfusion in all cases. Echocardiography was performed after 3–6 months, showing a mean pressure of 22.8 mm Hg (corrected values). There were no signs of recurrent PTE or arterial hypertension in the follow-up.

CONCLUSION

The data provided confirm the efficacy and safety of mechanical fragmentation and pharmacologic thrombolysis in the treatment of massive PTE with hemodynamic impairment, showing improvement of symptoms and a decrease in PAP.

Section snippets

Patient Population

From January 1994 until June 2000, 59 patients with diagnosed massive PTE with severe (life-threatening) hemodynamic instability were treated, 25 of them men (42.7%) and 34 women (57.6%), with a mean age of 54.5 y ± 2.08 (range, 22–85 y).

Patients were included who had acute PTE with a Miller index >0.5 (29) and a mean pressure in the main pulmonary artery greater than 30 mm Hg. None of them showed contraindications for fibrinolytic treatment. The Miller index is a quantitative parameter for

Early Results

Technical success (to achieve catheterization, fragmentation, and thrombolysis) was achieved in all cases. (Figure 1, Figure 2). The range of urokinase infusion time was 24 –72 hours and 20 minutes to 2 hours for rt-PA infusion.

After fragmentation and administration of the thrombolytic bolus, clinical improvement was seen in 56 patients (94.9%). This improvement was assessed by the decrease or disappearance of clinical symptoms and by the stabilization of the hemodynamic parameters of heart

DISCUSSION

Hemodynamically unstable massive thromboembolism is a clinical emergency requiring immediate and effective life-supporting therapeutic measures. Anticoagulation with heparin is the basic treatment of venous thromboembolic disease. Various studies have shown the efficacy of fractionated heparin and even lowmolecular-weight heparin for treating hemodynamically stable pulmonary embolism (31, 32).

Different authors have shown that the use of thrombolytic drugs for treatment of pulmonary embolism can

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