Intravascular Ultrasound-Guided Catheter-Based Aspiration Thrombectomy in Patients With Acute Submassive Pulmonary Embolism: A Case Series

• Published in: Cardiovascular revascularization medicine 2022-03, Vol.36, p.138-143
• Main Authors: Kumar, Gautam, Effoe, Valery S., Kumar, Arnav, Verma, Isha, Sachdeva, Rajesh
• Format: Article
• Language: English
• Subjects: Acute Disease; Catheters; Embolectomy; Fibrinolytic Agents - therapeutic use; Humans; Intravascular ultrasound; Intravenous contrast; Pulmonary embolism; Pulmonary Embolism - diagnostic imaging; Pulmonary Embolism - therapy; Renal failure; Thrombectomy; Thrombectomy - adverse effects; Thrombectomy - methods; Thrombolytic Therapy - adverse effects; Thrombolytic Therapy - methods; Treatment Outcome; Ultrasonography, Interventional
• ISSN: 1553-8389; 1878-0938
• DOI: 10.1016/j.carrev.2021.05.016

Contrast pulmonary angiography by hand injection or power injection is widely used during catheter-based therapies for acute submassive and massive pulmonary embolism (PE). Particularly, in patients with pre-existing chronic kidney disease, this approach may present a prognostic challenge owing to a double-contrast load, initially during computed tomographic pulmonary angiography (CTPA), and during percutaneous treatment. Intravascular ultrasound (IVUS) has been used as an adjunctive imaging modality in the percutaneous treatment of chronic thromboembolic pulmonary hypertension, and in coronary and peripheral vascular interventions. We report a series of cases illustrating the use of IVUS in the management of acute PE. All five patients presented with an acute submassive PE with evidence of right ventricular (RV) strain (RV/LV ratio ≥ 0.90). Body mass index and B-type natriuretic peptide ranged from 18 to 47 kgm/m2 and 56–932 pg/mL (ref. ≤ 78), respectively. Three of the five patients had renal impairment prior to the procedure (acute kidney injury, AKI, and chronic kidney injury, CKD). Post-catheter-directed pulmonary embolectomy there was a modest reduction in mean pulmonary artery pressure in all five patients (range: −4 mmHg to −9 mmHg). The first case serves as a proof of concept of IVUS use in acute PE. This case series demonstrates that an IVUS-only approach in the catheter-directed management of acute submassive PE is feasible and may be of particular importance in patients with pre-existing renal dysfunction. •IVUS can be used to facilitate contrast-free mechanical thrombectomy in acute submassive pulmonary embolism.•IVUS can be used to identify PA size and delineate thrombus burden.•IVUS can be used post-thrombectomy to identify extent of recanalization.