Combined Modality of Mechanical Breakdown and Intraembolus Thrombolysis in Failed Systemic Thrombolysis of Subacute Pulmonary Embolism Patients

Abstract

Acute massive pulmonary embolism with failed systemic thrombolysis has a high morbidity and mortality with few treatment options available. This study assesses the role of combined modality of mechanical fragmentation and intralesional thrombolysis in failed systemic thrombolysis. Seven (13.5%) of 52 patients with massive pulmonary embolism with persistent cardiogenic shock that failed systemic thrombolysis underwent imaging to confirm pulmonary embolism, and then mechanical fragmentation and intralesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4,400 IU/kg over 10 minutes followed by 4,400 IU/kg per hour over 24 hours). Four (57.1%) of 7 were unsuccessfully thrombolyzed outside the hospital by urokinase, 2 (28.6%) with recombinant tissue-type plasminogen activator (rtPA) and 1 (14.3%) with streptokinase systemically before 24-48 hours of admission. At presentation, average heart rate and shock index were 121.7/min and 1.45, respectively. Average systolic pulmonary arterial pressure was 73 ± 2.65 mmHg at presentation, and postoperatively was significantly reduced to 39.7 ± 10.44 mmHg (P < 0.001). Mortality at 24 hours, 30 days, and 2 years follow-up was 0% (0/7). Mechanical breakdown of thrombus followed by urokinase infusion may be a cost-effective, minimally invasive, and potentially life-saving procedure for the management of acute massive pulmonary embolism. Randomized controlled trials are required to compare this new strategy to contemporary conventional approaches.