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Catheter directed thrombolysis combined with ECMO for massive pulmonary emboli.

ABSTRACT: This case report discusses a previously healthy young male who suffered an in hospital cardiac arrest, found to be secondary to massive pulmonary emboli (PE). This patient was not a candidate for PE dosing of tPA, but continued to have worsening cardiogenic shock and acute hypoxic respiratory failure. The decision was made to initiate venoarterial extracorporeal membrane oxygenation (VA ECMO) in combination with catheter assisted thrombolysis. With time, the sequelae of his disease process changed. Although his cardiogenic shock improved, the hypoxemia worsened, and the patient was transitioned from VA to venovenous (VV) ECMO, while managing further complications due to multiple episodes of cardiac arrest and severe coagulopathy with multiple, acute, life-threatening bleeding events. Albeit a growing field, VA and VV ECMO are less than common, individually, however this case reports outlines the even rarer event of transition from VA to VV ECMO in combination with catheter assisted thrombolysis treatment via the EKOS EndoWave Infusion Catheter System. Providing care for critically ill patients often demands a collaborative effort between multiple specialties. This case report exemplifies this collaboration, leading to the combination and unification of alternative treatments: ECMO and catheter assisted thrombolysis.

SUBMITTER: Lauren Lindsey J

PROVIDER: S-EPMC5986164 | biostudies-other | 2018

REPOSITORIES: biostudies-other

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Catheter directed thrombolysis combined with ECMO for massive pulmonary emboli.

Lauren Lindsey J J Jain Rajay R Vachharajani Vidula V

Respiratory medicine case reports 20180531

This case report discusses a previously healthy young male who suffered an in hospital cardiac arrest, found to be secondary to massive pulmonary emboli (PE). This patient was not a candidate for PE dosing of tPA, but continued to have worsening cardiogenic shock and acute hypoxic respiratory failure. The decision was made to initiate venoarterial extracorporeal membrane oxygenation (VA ECMO) in combination with catheter assisted thrombolysis. With time, the sequelae of his disease process chang ...[more]

PMID: 29872632

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Project description:BackgroundThe post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome.MethodsWe randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up.ResultsBetween 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P=0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P=0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P=0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P=0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups.ConclusionsAmong patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335 .).

Dataset Information

Catheter directed thrombolysis combined with ECMO for massive pulmonary emboli.

Publications

Catheter directed thrombolysis combined with ECMO for massive pulmonary emboli.

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