Thrombectomy in high-risk pulmonary thromboembolism.

Abstract

An 83-year-old woman with a history of pulmonary thromboembolism 10 years ago was referred for dyspnea. Anticoagulation therapy was terminated by her family doctor 3 years previously. On admission , D-dimer level was 16.6 µg/mL and arterial blood gas showed 88.1% on room air. Pulmonary arteriography (PAG) revealed some filling defects, mainly in the right interlobar artery (figure 1A). Non-obstructive angioscopy (NOA) 1 showed two kinds of thrombi in the pulmonary arteries. At the translucent area, a massive, red, smooth thrombus was seen (figure 1B, video 1). Between the massive thrombus, floating, mobile, white-red, puff-like thrombi were demonstrated (figure 1C, video 2). As the thrombi entered the catheter spontaneously, aspiration was performed using a 20 mL syringe. Thrombi in the guiding catheter were collected by removing the guiding catheter. For the first trial, red thrombi were effectively aspirated (figure 1D). Puff-like thrombi in the truncus anterior, interlobar artery and basal trunk were aspirated while monitoring via NOA with a total of three trials, and arterial blood gas rapidly improved by 97.9% on room air. PAG showed diminished deficit, and additional anticoagulation therapy was continued for 3 weeks. In the acute phase of pulmonary thromboembo-lism, selective aspiration thrombectomy was effectively performed by observing the features of the thrombi using NOA. In case of recurrent pulmonary thromboembolism, acute and chronic thrombi may occlude the pulmonary arteries. Acute thrombi may be soft and easier to deform and aspirate compared with chronic thrombi. Chronic thrombi can be difficult to aspirate because they are solid due to organisation.