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Catheter-based therapy for acute pulmonary embolism: Lifesaving in a clinical dilemma!

Paul G, Birinder P, Parshotam G - Indian J Crit Care Med (2015)

View Article: PubMed Central - PubMed

Affiliation: Critical Care Medicine, Dayanand Medical College, Ludhiana, Punjab, India.

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After confirming the diagnosis, mechanical fragmentation was initiated in the embolus followed by intralesional urokinase [Figure 1]... Over the next 24 hrs, hemodynamic parameters gradually improved with the resolution of shock and reduction in pulmonary artery pressure to 27 mmHg... ABG showed respiratory acidosis which in not a common finding in patients of PE, but our patient had neuromuscular paralysis of respiratory and accessory muscles which precluded him from hyperventilation and resulted in respiratory acidosis as the first change in ABG... Thus, the presence of respiratory acidosis on ABG does not exclude the possibility of PE as quoted in one of the recent articles rather blood gas must never be analyzed alone but should be correlated to the clinical scenario... The American college of chest physicians consensus statement have laid down recommendations for management of PE but not more than two-thirds of the patients receive systemic thrombolysis because it is contraindicated (absolute or relative) in a large number of clinical conditions... Although our patient was a candidate for systemic thrombolysis, but refractory arterial hypotension and the need for CPR led to the selection of CDT as the modality of choice... Two hour period required for infusion of full dose of tPA and about 20% risk of major hemorrhage following its infusion also led to the selection of CDT as the first line therapy... The catheter-based fragmentation leads to mechanical debulking which can be clinically seen as an immediate improvement in hemodynamics, resolution of shock, and reduction in PASP... However, breakdown of the clot provides a large exposed area for subsequent thrombolysis... The thrombolytic infusion following debulking results in decreasing the incidence of chronic PE and pulmonary hypertension... It is a plasminogen activator with the additional quality of a catalytic agent that renders fibrinogen less clottable by thrombin... Furthermore, in terms of cost and availability it was chosen as the preferred agent... This case highlights that clinicians should have a low threshold for diagnosing PE in acutely bed ridden patients... In a selected group of patients with neurological disorders where systemic thrombolysis is contraindicated, combination of mechanical fragmentation and local thrombolysis may be a promising option for reduction in mortality.

No MeSH data available.


Pulmonary angiography (a) total cut-off of right pulmonary artery (RPA) and clot in left PA (b) mechanical breakdown and intrapulmonary urokinase administration (c) postprocedural pulmonary angiography revealing restoration of pulmonary flow in PA and its branches
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Figure 1: Pulmonary angiography (a) total cut-off of right pulmonary artery (RPA) and clot in left PA (b) mechanical breakdown and intrapulmonary urokinase administration (c) postprocedural pulmonary angiography revealing restoration of pulmonary flow in PA and its branches

Mentions: 22-year-male, (body mass index 34) with Guillain-Barre Syndrome was on treatment with plasmapheresis. He suddenly became hemodynamically unstable on the 5th day of hospitalization. Arterial blood gas (ABG) showed hypercapnia and later hypoxia. Electrocardiograph showed sinus tachycardia. Echocardiography revealed hypokinesia of the right ventricle and moderate tricuspid regurgitation with pulmonary artery systolic pressure (PASP) of 45 mmHg. The patient continued to be hypoxemic, hypotensive, and suffered a cardiac arrest. In view of deteriorating status, the patient was taken for pulmonary angiography with the intention to diagnose as well treat pulmonary embolism in the same setting. After confirming the diagnosis, mechanical fragmentation was initiated in the embolus followed by intralesional urokinase [Figure 1]. Over the next 24 hrs, hemodynamic parameters gradually improved with the resolution of shock and reduction in pulmonary artery pressure to 27 mmHg.


Catheter-based therapy for acute pulmonary embolism: Lifesaving in a clinical dilemma!

Paul G, Birinder P, Parshotam G - Indian J Crit Care Med (2015)

Pulmonary angiography (a) total cut-off of right pulmonary artery (RPA) and clot in left PA (b) mechanical breakdown and intrapulmonary urokinase administration (c) postprocedural pulmonary angiography revealing restoration of pulmonary flow in PA and its branches
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4478687&req=5

Figure 1: Pulmonary angiography (a) total cut-off of right pulmonary artery (RPA) and clot in left PA (b) mechanical breakdown and intrapulmonary urokinase administration (c) postprocedural pulmonary angiography revealing restoration of pulmonary flow in PA and its branches
Mentions: 22-year-male, (body mass index 34) with Guillain-Barre Syndrome was on treatment with plasmapheresis. He suddenly became hemodynamically unstable on the 5th day of hospitalization. Arterial blood gas (ABG) showed hypercapnia and later hypoxia. Electrocardiograph showed sinus tachycardia. Echocardiography revealed hypokinesia of the right ventricle and moderate tricuspid regurgitation with pulmonary artery systolic pressure (PASP) of 45 mmHg. The patient continued to be hypoxemic, hypotensive, and suffered a cardiac arrest. In view of deteriorating status, the patient was taken for pulmonary angiography with the intention to diagnose as well treat pulmonary embolism in the same setting. After confirming the diagnosis, mechanical fragmentation was initiated in the embolus followed by intralesional urokinase [Figure 1]. Over the next 24 hrs, hemodynamic parameters gradually improved with the resolution of shock and reduction in pulmonary artery pressure to 27 mmHg.

View Article: PubMed Central - PubMed

Affiliation: Critical Care Medicine, Dayanand Medical College, Ludhiana, Punjab, India.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

After confirming the diagnosis, mechanical fragmentation was initiated in the embolus followed by intralesional urokinase [Figure 1]... Over the next 24 hrs, hemodynamic parameters gradually improved with the resolution of shock and reduction in pulmonary artery pressure to 27 mmHg... ABG showed respiratory acidosis which in not a common finding in patients of PE, but our patient had neuromuscular paralysis of respiratory and accessory muscles which precluded him from hyperventilation and resulted in respiratory acidosis as the first change in ABG... Thus, the presence of respiratory acidosis on ABG does not exclude the possibility of PE as quoted in one of the recent articles rather blood gas must never be analyzed alone but should be correlated to the clinical scenario... The American college of chest physicians consensus statement have laid down recommendations for management of PE but not more than two-thirds of the patients receive systemic thrombolysis because it is contraindicated (absolute or relative) in a large number of clinical conditions... Although our patient was a candidate for systemic thrombolysis, but refractory arterial hypotension and the need for CPR led to the selection of CDT as the modality of choice... Two hour period required for infusion of full dose of tPA and about 20% risk of major hemorrhage following its infusion also led to the selection of CDT as the first line therapy... The catheter-based fragmentation leads to mechanical debulking which can be clinically seen as an immediate improvement in hemodynamics, resolution of shock, and reduction in PASP... However, breakdown of the clot provides a large exposed area for subsequent thrombolysis... The thrombolytic infusion following debulking results in decreasing the incidence of chronic PE and pulmonary hypertension... It is a plasminogen activator with the additional quality of a catalytic agent that renders fibrinogen less clottable by thrombin... Furthermore, in terms of cost and availability it was chosen as the preferred agent... This case highlights that clinicians should have a low threshold for diagnosing PE in acutely bed ridden patients... In a selected group of patients with neurological disorders where systemic thrombolysis is contraindicated, combination of mechanical fragmentation and local thrombolysis may be a promising option for reduction in mortality.

No MeSH data available.