Fibrinolysis and mechanical fragmentation to treat hemodynamically unstable massive pulmonary embolism: one center´s experience in 111 patients
Sánchez Ballestin M, Medrano J, Laborda A, Bosch J, De Blas I, Mainar A, Fredes A, De Gregorio MA
Purpose: To present our series of in situ fibrinolysis after mechanical fragmentation in hemodynamically unstable massive PTE.
Materials and Methods: 111 patients were treated from 2001 to 2009 in a single center. Inclusion criteria were: massive PTE and two of the following: systolic blood pressure < 90mmHg, Miller index > 0.5, ventricular dysfunction or need for vasoactive drugs. Exclusion criteria were: pregnancy, surgery in the previous 72 hours, several head trauma, stroke in the last 6 months, uncontrolled hypertension, severe coagulopathy, severe hepatic or renal failure. Average age of the patients was 56.6 years (range 27-79). The predominant symptom was dyspnea (70.2%). In 23.1% patients, syncope was the debording symptom. Wells score, Miller index and mean pulmonary artery pressure were recorded. Mechanical fragmentation was performed in 84.1% of the patients and fibrinolysis with urokinase (100.00UI/hour, 12-24 hours) was performed in all cases. In 88% of the patients an optional IVC filter was implanted.
Results: Technical success was 100%. Mechanical fragmentation and initial bolus of urokinasa did not modified significantly the PA pressure, but the standard 12-24 h treatment modified significantly the PA pressure (P < 0.01) and Miller index (P < 0.01). Mean follow up was of 54.3 months, with no signs of PTE. Minor complications were 4 deaths within 30 days (1 cerebral hematoma and 3 deaths as a consequence of right heart failure).
Conclusion: In situ fibrinolysis is a useful and efficient treatment for hemodynamically unstable massive PTE, improving heart work (decreasing PAP) and allowing central venous monitorization and fragmentation.