A Case of Acute Massive Pulmonary Thromboembolism Treated by Mechanical Clot Fragmentation Using a Percutaneous Transluminal Angioplasty Balloon

Abstract

Large, bilateral central pulmonary thromboemboli (PTE) led to cor pulmonale and severe hypoxemia in a patient who had undergone Hardy's operation. After several unsuccessful efforts (thrombolysis using a percutaneous catheter and aspiration of the emboli), mechanical clot fragmentation using a percutaneous transluminal angioplasty (PTA) balloon was attempted. This procedure was successful, resulting in a decrease in pulmonary artery pressure from 58/22 (mean 34) mmHg to 20/10 (mean 13) mmHg together with an increase in aortic pressure from 64/36 (mean 45) mmHg to 112/60 (mean 77) mmHg. Thus, mechanical clot fragmentation using a PTA balloon is a promising method for reducing pulmonary artery pressure and increasing aortic pressure in patients with acute PTE.

When should we thrombolyse patients with pulmonary embolism? A systematic review of the literature

“…57 Cardiac catheterisation, mechanical fragmentation techniques, high velocity jet fragmentation, and combinations of mechanical clot disruption with low/usual dose thrombolysis have all been described in case reports/case series but there is no published trial evidence. [58][59][60][61][62][63][64][65] It is unlikely that adherent clot more than 48-72 hours old is removable. 58 59 There is no randomised trial of medical versus surgical therapy.…”

Mechanical clot fragmentation using a Swan–Ganz catheter is useful for acute massive pulmonary thromboembolism

“…Then, mechanical clot fragmentation using a SGC was attempted, and this procedure was successful, resulting in a decrease in pulmonary artery pressure with improvement in hypoxemia. Although different devices for mechanical thrombectomy are available (such as pigtail catheter, guide wire, percutaneous transluminal angioplasty balloon, and special thrombofragmentation devices) [4,5], this is the first report to demonstrate that mechanical clot fragmentation using a SGC may be useful for patients with massive PE with contraindications to thrombolytic therapy.…”

“…As mentioned above, different devices for mechanical thrombectomy are available [4,5], however the careful use of a SGC may be associated with the lowest risk of physical injury because SGCs are designed for use even in healthy persons, unlike other modalities. We have also used an 8 Fr guiding catheter for aspiration of thrombi since 1996 [5], however, this procedure could create only a small cannel in the clot and was often unsuccessful for improvement of pulmonary hypertension or hypoxemia. On the other hand, clot fragmentation using SGC has created many cannels in the clots, resulting in reduced pulmonary artery pressure and improving hypoxemia.…”