Usefulness of aspiration of pulmonary emboli and prolonged local thrombolysis to treat pulmonary embolism.

Catheter-based treatment of pulmonary embolism (PE) has been demonstrated to be successful in case reports and small series. The investigators report the results of a novel, pharmacomechanical approach with prolonged infusion of urokinase in the occluded pulmonary arteries (PAs). Manual aspiration of thrombus using guide catheters was followed by introduction of thrombolysis catheters and a local bolus of urokinase. The lysis catheters were left in place, and repeat PA cine angiography and right-sided cardiac catheterization was performed 3 days later. A total of 63 patients (mean age 60 ± 15 years) were treated over 8 years: 17 patients (27%) had massive and 46 patients (73%) submassive PE. The mean PA pressure was 35 ± 10 mm Hg, and 54% had central bilateral PE. Five patients died, 1 before, 1 during, and 3 after the intervention. Nine patients (14%) had major bleeds (hemoglobin decrease >30 g/L), but in none of these patients was bleeding the reason for fatal outcome. After 3.3 ± 1.0 days, 49 of 58 living patients (84%) were restudied. In 29 (59%), there was a reduction of thrombotic burden by >90%, and in 14 (29%), the reduction was 50% to 90%. Mean PA pressure was reduced from 33 ± 8 to 21 ± 7 mm Hg (p <0.001), and this was not dependent on a reduction of thrombus. In conclusion, manual aspiration and application of prolonged thrombolysis is feasible and safe. Improvement of PA pressures is impressive and there is no correlation between morphologic disappearance of thrombus and normalization of PA pressures.