The Interventional Therapies For Acute Massive Pulmonary Embolism

Objective: Acute massive pulmonary embolism (PE) is a clinical emergency requiring rapid and supportive measures. Anticoagulation, thrombolysis and surgery are the three traditional therapies. Thrombolysis is easy to perform but cannot reduce the pulmonary artery pressure (PAP) and right ventricular afterload rapidly. And on the other hand, surgical operation requires experienced experts and good facilities, even so higher risks and more complications exist. With the development of interventional technology and devices, percutanous mechanical thrombectomy(PMT) is considered as a treatment option, though the clinical experience is rare. The purpose of this study is to evaluate the clinical efficacy and safety of PMT in the management of acute massive PE.Methods: The data of massive PE patients treated with interventional methods were collected in a retrospective way. From Jan 2003 to Jun 2007, 28 patients (20 men, 8 women; mean age 64 years) with acute massive PE initially diagnosed by computed tomography and confirmed by pulmonary angiography were treated with inferior vena caval filter placement and percutaneous catheter fragmentation. Twenty-six patients received thrombolytic agent after embolus fragmentation. From March 2003 to January 2008, five patients (4 men, 1 woman) with a mean age of 52.4 (range, 38-64) years with acute massive PE initially diagnosed by computed tomography (CT) and confirmed by pulmonary angiography. All patients presented with acute PE symptoms. Each patient was treated with Straub Rotarex thrombectomy device and one patient received additional thrombolysis.Results: Catheter fragmentation group: The improvement of clinical status and restoration of blood flow in the main branches of pulmonary artery were seen in 27 patients. Only one case didn't benefit from the percutaneous therapy and died during the procedure of surgical thromboectomy attempt. Oxygen saturation (Sat.O2) increased from 86.2%±4.5% to 96.1%±3.2% (P<0.001) after interventional procedure. The post-procedure mean pulmonary artery pressure (PAP) decreased from (34.2±4.8) mmHg to (25.2±5.1) mmHg (P<0.001). During clinical follow-up (range, 1-5 years), all patients had no recurrence of PE. Straub Rotarex thrombectomy group: The post-PMT mean PAP deceased from 41.8±7.9mmHg to 30.7±8.5mmHg (p<0.01). Sat.O2 increased from 79.0%±4.3% to 92.8%±3.5% (p<0.01) after PMT procedure.Conclusions: The preliminary experience in our series suggests percutaneous catheter fragmentation combined with thrombolysis is an easy, effective and safe therapy in the clinical management of acute massive PE, especially when the thrombus is fresh and located in the trunk of pulmonary artery. However, commercial PMT devices are required if it is proved or estimated that simple catheter fragmentation unefficient. The Straub Rotarex system is useful and safe in the treatment of acute massive PE as a new PMT system.