Treatment of high- and intermediate-risk pulmonary embolism using the AngioJet percutaneous mechanical thrombectomy system in patients with contraindications for thrombolytic treatment - a pilot study.

Abstract

IntroductionIntravenous thrombolysis is the treatment of choice in patients presenting with high- and intermediate-risk pulmonary embolism. The role of percutaneous mechanical pulmonary thrombectomy (PMPT) is not fully established, although selected patients can be managed with this method.AimThis open-label single-centre prospective pilot study was aimed at assessing the feasibility of PMPT for the treatment of severe pulmonary embolism in a Polish hospital. We also evaluated the safety and efficacy of such management.Material and methodsWe managed 7 patients, aged 52.7 ±16.6 years, presenting with high- and intermediate-risk pulmonary embolism (4 patients with class 5 and one patient with class 4 of the Pulmonary Embolism Severity Index), with occlusion of at least 2 lobar arteries and contraindications for thrombolysis. Percutaneous mechanical pulmonary thrombectomy was performed using the AngioJet system.ResultsIt was possible to introduce the thrombectomy system to the pulmonary arteries in all patients. The procedure was successful in 6 patients (technical success rate: 85.7%). Two (28.6%) patients died during the hospital stay, one patient with unsuccessful thrombectomy and the other due to pneumonia. In all survivors control echocardiography demonstrated normalised function of the right ventricle. Also, dyspnoea disappeared and blood gas parameters normalised. There was no recurrent thromboembolism during 3–14 months of follow-up.ConclusionsIn the Polish setting, in selected patients, management of high- and intermediate-risk pulmonary embolism with PMPT is technically feasible. Such treatment is relatively safe and effective. It can be an alternative to standard management, especially in patients with contraindications for fibrinolysis or surgical embolectomy.

Implementation of a regional multidisciplinary pulmonary embolism response team: PERT-POZ initial 1-year experience

“…4,30 However, as a result of recent development of interventional cardiology, percutaneous techniques (CDT) became an important alternative to SE. 5,[7][8][9]15,18,29,[31][32][33][34][35][36][37][38] They are aimed to quickly relive obstruction and restore pulmonary blood flow, thus increasing cardiac output and immediately restoring hemodynamical stability. 39 In the present study, all patients with high -risk PE received advanced therapy: ST or, in the presence of contraindications, SE or CDT.…”

Endovascular therapies for pulmonary embolism

“… Authors, year Period covered by review Aim and main points of the review Number of studies included Kuo et al, 2009 [ 35 ] January 1990–September 2008 Non-comparative data meta-analysis Efficacy and safety of catheter-directed treatment for massive pulmonary embolism (thrombolysis, mechanical, aspiration, catheter-directed thrombolysis) N = 35 Engelberger et al, 2014 [ 18 ] ND General review of efficacy and safety data on the use of ultrasound-assisted thrombolysis in acute pulmonary embolism. Pooled analysis (non-comparative data meta-analysis) of the data from the main studies N = 7 Ierardi et al, 2015 [ 40 ] January 2000–June 2015 General review of clinical experience worldwide with pharmacomechanical thrombolysis (AngioJet™) N = 19 Bajaj et al, 2016 [ 39 ] 1966–September 2015 Meta-analysis of the use of catheters for acute pulmonary embolism N = 62 Mostafa et al, 2016 [ 19 ] 2008–September 2015 Non-comparative data meta-analysis Efficacy and safety of ultrasound-assisted thrombolysis for acute pulmonary embolism N = 11 Zarghouni et al, 2016 [ 41 ] ND General review of different catheter-directed methods to treat pulmonary embolism and results of the main studies in the literature according to the authors N = 7 ND: not determined. …”

“…Although very efficient for peripheral venous thrombosis, a number of issues are associated with its use for PE [ 38 ]. Indeed, despite many reports of good clinical results, various serious complications have been described, in particular bradycardia, arrhythmia, hypotension and haemoglobinuria associated in rare cases with kidney failure [ 39 , 40 , 41 ]. These complications may result from the haemolysis caused by clot fragmentation which may trigger massive release within the pulmonary arteries of neurohormonal agents such as adenosine and bradykinin.…”

“…Pressure-pulsed delivery of saline at the catheter's distal tip fragments the thrombus and creates a Venturi effect that aspirates and removes the fragments via a second lumen. It is important to note, however, that these results are somewhat dated, with a device and technique that have evolved with time [ 40 , 41 , 42 ]. …”

Expert opinion on the creating and operating of the regional Pulmonary Embolism Response Teams (PERT). Polish PERT Initiative

“…In the published meta-analysis of Bajaj et al [23], periprocedural success, defined as hemodynamic stabilization, reduction of hypoxia and discharge from hospital, was achieved in 87% of patients treated with endovascular treatment. The first Polish experiences with transcatheter methods (AngioJet system, Indigo Penumbra aspiration thrombectomy, EKOS system and Cleaner system) have recently been published [24][25][26][27][28][29].…”