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Hybrid Treatment of Acute Massive Pulmonary Thromboembolism: Mechanical Fragmentation with a Modified Rotating Pigtail Catheter, Local Fibrinolytic Therapy, and Clot Aspiration Followed by Systemic Fibrinolytic Therapy

Hiroyuki Tajima1, Satoru Murata1, Tatsuo Kumazaki1, Ken Nakazawa1, Yutaka Abe1, Yasushige Komada1, Pascal Niggemann1, Morimasa Takayama2, Keiji Tanaka2 and Teruo Takano2

1 Department of Radiology, Center for Advanced Medical Technology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8601, Japan.
2 Department of Internal Medicine 1, Coronary Care Unit, Nippon Medical School, Tokyo 113-8601, Japan.



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  		Fig. 1A. —Catheter system for manual fragmentation of pulmonary thromboembolism. Photograph shows 6-French curved pigtail catheter for pulmonary angiography (K-PA catheter, Medi-kit) that is used during procedure.

 


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  		Fig. 1B. —Catheter system for manual fragmentation of pulmonary thromboembolism. Photograph shows 260-cm guidewire (Radifocus, Terumo), proximal tip of which is inserted into most proximal side hole of curved pigtail catheter. Catheter is first inserted over guidewire and through pulmonary artery sheath and is then withdrawn, leaving guidewire in peripheral pulmonary artery.

 


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  		Fig. 2A. —51-year-old man with advanced lung cancer who experienced sudden onset of dyspnea. Pulmonary angiogram shows massive emboli in right pulmonary artery. Pulmonary artery pressure was 42/13 (mean, 25) mm Hg, and Miller score [7] was 18.

 


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  		Fig. 2B. —51-year-old man with advanced lung cancer who experienced sudden onset of dyspnea. Pulmonary angiogram shows modified rotating pigtail catheter inserted for fragmentation of emboli.

 


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  		Fig. 2C. —51-year-old man with advanced lung cancer who experienced sudden onset of dyspnea. On pulmonary angiogram, percutaneous transluminal coronary angioplasty guide catheter (8-French Guider Softip, Boston Scientific, SciMed Life Systems) is inserted for clot aspiration.

 


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  		Fig. 2D. —51-year-old man with advanced lung cancer who experienced sudden onset of dyspnea. Pulmonary angiogram shows improved perfusion after combined therapy, although some thrombi remain in lower branches of artery. Posttreatment pulmonary artery pressure was 35/8 (19) mm Hg, and Miller score was 9. Total treatment time was 145 min.

 


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  		Fig. 2E. —51-year-old man with advanced lung cancer who experienced sudden onset of dyspnea. Angiogram was obtained 6 days after treatment (total dose of urokinase, 144 x 104 IU/6 days). Postclinical course was uneventful, but patient died of lung cancer 135 days after treatment.

 


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  		Fig. 3A. —67-year-old woman who suddenly went into shock 2 days after surgery for gastric cancer, necessitating mechanical ventilation. Pulmonary angiogram shows massive emboli in right pulmonary artery. Shock index was 1.21, pulmonary artery pressure was 42/23 (mean, 32) mm Hg, and Miller score [7] was 27.

 


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  		Fig. 3B. —67-year-old woman who suddenly went into shock 2 days after surgery for gastric cancer, necessitating mechanical ventilation. Pulmonary angiogram shows improvement of perfusion after combined therapy. Posttreatment shock index was 0.70, pulmonary artery pressure was 38/21 (26) mm Hg, and Miller score was 14. Total treatment time was 108 min.

 


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  		Fig. 3C. —67-year-old woman who suddenly went into shock 2 days after surgery for gastric cancer, necessitating mechanical ventilation. Final angiogram was obtained 5 days after treatment. Patient was discharged 43 days after treatment (total dose of urokinase, 288 x 104 IU/6 days).

 

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