Endovascular Treatment of a Haemodynamically Unstable Massive Pulmonary Embolism using Fibrinolysis and Fragmentation. Experience with 111 Patients in a Single Centre. Why don’t we follow ACCP Recommendations?

• Published in: Archivos de bronconeumología (English ed.) 2011, Vol.47 (1), p.17-24
• Main Authors: Ángel de Gregorio, Miguel, Laborda, Alicia, de Blas, Ignacio, Medrano, Joaquín, Mainar, Antonio, Oribe, Mikel
• Format: Article
• Language: English
• Subjects: Adult; Aged; Combined Modality Therapy; Embolismo pulmonar masivo; Endovascular Procedures; Female; Fibrinolisis; Fibrinolysis; Fragmentación; Fragmentation; Guideline Adherence; Hemodynamics; Humans; Internal Medicine; Male; Massive pulmonary embolism; Middle Aged; Practice Guidelines as Topic; Pulmonary Embolism - physiopathology; Pulmonary Embolism - therapy; Pulmonary/Respiratory; Retrospective Studies; Thrombolytic Therapy
• ISSN: 1579-2129; 1579-2129
• DOI: 10.1016/S1579-2129(11)70004-0

Abstract Introduction Fibrinolysis is recommended in several consensus documents for the treatment of hemodynamically-unstable massive pulmonary embolism (MPE). Material and methods A total of 111 patients were treated in a single center from January 2001 to December 2009. Fifty-five were male and 56 female, all diagnosed with hemodynamically-unstable MPE (systolic arterial pressure > 90 mmHg) with at least two of the following criteria: Miller index > 0, ventricular dysfunction, and need for vasoactive drugs. Local fibrinolysis with urokinase was performed in all cases as was fragmentation with a pig-tail catheter in most. An inferior vena cava (IVC) filter was implanted in 94 patients as a prophylactic measure. Results Technical success was 100%. The Miller index improved from 0.7 ± 0.12, pre-treatment, to 0.09 ± 0.16. Mean pulmonary arterial pressure went from 39.93 ± 7.0 mmHg to 20.47 ± 3.3 mmHg at the 30-90 day follow-up. Ninety-four patients had IVC filters implanted, 79% of which were withdrawn satisfactorily. Seven patients died: 3 due to neoplasia; 3 due to right cardiac failure at 1, 7 and 30 days; and another died of a brain hemorrhage within the first 24 hours. There were complications in 12.6% of the cases, of which 4.5% were major. Conclusion Local fibrinolysis with fragmentation achieves rapid normalization of the pulmonary pressure and is a safe and effective method for the treatment of hemodynamically-unstable MPE.