Rapid clinical and haemodynamic improvement in a patient with intermediate-high risk pulmonary embolism treated with transcatheter aspiration thrombectomy

A 59-year-old man with a history of colon cancer treated surgically three weeks ago was admitted with sudden dyspnoea and chest pain. Three days earlier he developed deep vein thrombosis of the left lower extremity and was treated with full dose low-molecular weight heparin. Physical examination revealed blood pressure 125/70 mm Hg, heart rate 125/min, respiratory rate 28/min. In laboratory tests NT-proBNP was 1961 pg/ml, troponin I 0.4 mg/dl (r.v. < 0.01 mg/dl), arterial oxygen saturation (SaO2) 88%. Echocardiography revealed signs of right ventricular (RV) enlargement (RV/LV index = 1.9) and hypokinesis of the free RV wall. In computed tomography bilateral massive thrombi affecting lobar pulmonary arteries were observed. Based on these results the patient was diagnosed with intermediate-high risk pulmonary embolism (PE). Calculated PESI score was 139 points (class V – very high risk). Due to relative contraindications to systemic thrombolysis our local Pulmonary Embolism Response Team (PERT) decided to treat this patient with catheter-directed thrombectomy (CDT). Pulmonary angiography was made from right femoral vein access and revealed massive PE especially in the left pulmonary artery (Figure 1 A) [1]. Pulmonary artery pressure was 45/22/32 mm Hg. An intravenous bolus of 7000 IU of unfractionated heparin was administered at the beginning of the procedure. Continuous mechanical aspiration thrombectomy was subsequently performed with a 115 cm 8 Fr Indigo CAT8 TORQ catheter (Penumbra, Almeda, Ca, USA). A separator wire was repeatedly passed through the thrombus to break it down and allow it to be suctioned through the catheter. The thrombus was fragmented and partially removed (Figure 1 B) but distal embolization in the intermediate branch and lower segmental branches appeared (A4-5, A10). For this reason we continued aspiration and entered selectively segmental branches using the support of 6 Fr Judkins Right diagnostic coronary catheter and 0.014 coronary guide-wire to restore and improve the pulmonary flow (Figure 1 B). The decision to terminate the procedure was taken after evaluation of haemodynamic parameters (pulmonary artery pressure decreased to 28/11/16 mm Hg and SaO2 to 93%) and also the total amount of aspirated blood (350 ml). After the procedure the clinical status of the patient rapidly improved. Anticoagulation was continued with body weight-adjusted low-molecular-weight heparin. On the second day after the procedure normalisation of...


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