Mechanical and Enzymatic Thrombolysis of Acute Pulmonary Embolus: Review of the Literature and Cases from Our Institution

Abstract

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Patients with massive PE have a high mortality rate, with two of every three deaths occurring in the first hour. The mainstay of treatment for PE is anticoagulation. However, when the patient is in extremis, intravenous lysis of the clot is indicated. Recently, mechanical fragmentation with or without pharmacologic thrombolysis has been shown to have a role in therapy for patients with massive PE, as well as in those patients who have a contraindication to anticoagulation. We discuss our experience with mechanical fragmentation in the treatment of PE and review the literature.

Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review

“…We found seven cases of severe PE treated with percutaneous fragmentation or thromboaspiration without thrombolysis (six massive PEs and one of uncertain severity; Table 2 and Table S2). Five had a diagnosis of PE before delivery [20,[37][38][39][40] and two in the early postpartum period [41,42]. Procedures were thrombus aspiration, fragmentation of thrombi by catheter or rheolytic thrombectomies.…”

A comparison of the ADC and T 2 mapping in an assessment of blood-clot lysability

“…The two-hour period was chosen to mimic the time course of thrombolysis in treating a massive pulmonary embolism (30,31). The ADC and T 2 maps acquired during the thrombolysis enabled the selection of limiting ADC and T 2 values, by which the regions of the clot could be divided into two parts: the efficiently lysable part and the poorly lysable part.…”

Successful Treatment of Peripartum Massive Pulmonary Embolism with Extracorporeal Membrane Oxygenation and Catheter-Directed Pulmonary Thrombolytic Therapy

“…These include systemic thrombolytic therapy, surgical thromboembolectomy and catheter-directed therapy. The latter includes different techniques, with or without pharmacological thrombolysis and mechanical embolectomy, including catheter-directed mechanical embolectomy and catheter-directed thrombolytic therapy, with or without mechanical fragmentation of the clot 8 . The surgical selection of pregnant patients with decompensated pulmonary hypertension secondary to massive pulmonary embolus is complex and depends upon carefully defined factors such as the accessibility and presumed age of the thrombi defined by angiography, the degree of haemodynamic or ventilatory impairment as a consequence of the thromboembolic vascular obstruction, and risk-benefit of the intervention to both mother and foetus.…”

“…There are very few reports in the literature of catheter-directed local thrombolytic therapy for the treatment of pulmonary embolism during pregnancy [8][9][10][11] . The primary goal of a catheter-based approach to thrombolytic therapy is to improve the rate and efficiency of clot dissolution, with minimal risk of systemic fibrinolysis.…”