Use of rheolytic thrombectomy in treatment of acute massive pulmonary embolism.

PURPOSE

The 6-F Xpeedior (AngioJet; Possis Medical, Minneapolis, MN) rheolytic thrombectomy catheter (RTC) uses high velocity saline jets for thrombus aspiration, maceration, and evacuation, through the Bernoulli principle. The purpose of this study was to evaluate the efficacy of thrombus removal using the RTC in patients with acute massive pulmonary embolism (PE).

MATERIALS AND METHODS

Seventeen patients (mean age, 51.7 + 16.6 years; range, 30-86 years; 9 men, 8 women) with massive PE initially diagnosed by computed tomography (CT) or VQ scan and confirmed by pulmonary angiography were treated with the RTC. All patients had acute onset of PE symptoms and all presented with hemodynamic compromise and dyspnea. Ten of 17 patients had enough residual thrombus to warrant adjuvant catheter directed thrombolytic infusion with reteplase. Six patients had contraindications to thrombolytic therapy. One patient presented with renal cell carcinoma and tumor embolus as suspected cause of PE. Angiographic and clinical outcomes during the hospital stay were evaluated.

RESULTS

The RTC was successfully delivered and operated via a 0.035-inch guide wire in all attempted cases. Treatment resulted in immediate angiographic improvement and initial relief of PE symptoms (improvement in dyspnea and oxygen saturation) in 16 of 17 patients. One patient developed heart block during the procedure, and further treatment with the RTC was discontinued. Bradycardia occurred in one patient (managed with lidocaine). After thrombectomy, 10 patients received adjunctive reteplase thrombolysis for treatment of residual thrombus, and 12 received inferior vena cava (IVC) filters. In the patient with renal cell carcinoma, histopathologic analysis of the evacuated material confirmed tumor origin of the embolism. There were two deaths, both within 24 hours of treatment and secondary to PE. One death occurred in a patient who had only minimal thrombus removal after treatment with the RTC and no thrombolysis. The remaining 15 patients showed continued improvement in PE symptoms and were eventually discharged from the hospital with mean length of stay 10.3 + 6.5 days (range, 5-30 days).

CONCLUSIONS

Rheolytic thrombectomy can be performed effectively in patients with massive PE. However, a large portion of the patients in this study underwent adjuvant overnight thrombolytic infusion. Further evaluation in a larger cohort of patients is warranted to assess whether this treatment may offer an alternative or complement to thrombolysis or surgical thrombectomy.