pulmonary embolism resolved with site specific thrombolysis via drug delivery catheter
DESCRIPTION
Pulmonary Embolism Resolved with Site Specific Thrombolysis via Drug Delivery Catheter. Michael Nuyles , DO Interventional Cardiology Fellow Midwestern University Franciscan Alliance – Olympia Fields, IL Michael Nicholas, DO, FACC, FACOI Interventional Cardiology Program Director. - PowerPoint PPT PresentationTRANSCRIPT
Pulmonary Embolism Resolved with Site Specific Thrombolysis via Drug
Delivery Catheter
Michael Nuyles, DOInterventional Cardiology FellowMidwestern University Franciscan Alliance – Olympia Fields, IL
Michael Nicholas, DO, FACC, FACOIInterventional Cardiology Program Director
Active, 81 year old Caucasian Female presented with progressive
debilitating dyspnea on exertion, chest tightness, and lightheadness.
Case Presentation• Medical History:– HTN, Dyslipidemia, Mild TR (prior ECHO
2008)• Surgical History: –Hysterectomy
• Social History:– Lifelong non-smoker, no EtOH/Illicits – Avid bicyclist, exercises daily
• Meds: – Simvastatin, ASA, Amilodipine, Atenolol
• Family History:– No Hx of malignancy or coagulopathy
• Physical Exam: –Afebrile , BP121/84, HR 81, RR 24, 94% on 4
liters O2 nasal cannula–CVS: RR, S1, S2 positive Carvallo’s Sign– Lungs: CTA– EXT: Tr Edema
CT Angiography and Echo
CTA Chest: Extensive bi-lateral pulmonary emboli upper and lower lobe
ECHO: - RV mod/severely dilated with reduced systolic function- Mod/severe TR - RVSP 57.1 mmHg
Procedural Course
• 7Fr sheath via Right Internal Jugular Vein• 7Fr Ansel 1 Flexor peripheral sheath• Terumo ™ Glidewire-angled-stiff 180 cm Guidewire• 5Fr. Pigtail catheter with attempted unsuccessful mechanical thrombolysis
Modern CDT vs. Systemic tPA(for Treatment of Acute PE)
Mortality from PE
Major Complications
Cerebral Hemorrhage
Modern CDTMeta-Analysis 2008
n = 308
12% 2.3%*
(7/308)
0%
Systemic tPAICOPER 1999
n = 304
23% 21.7%**
(66/304)
3%
(9/304)
*Includes 1.3% major hemorrhages. **All were major hemorrhages.
Courtesy of Anthony Venbrux, MD
Intra-clot administration of tissue plasminogen activator (tPA) into the pulmonary arteries 8 mg total using a ClearWay™ drug delivery balloon OTW
4 .0 x 20 mm
Procedural Course
Pre and Post tPA Pulmonary Artery Pressures
Pre Intervention ECHO Post Intervention ECHO- Day 9Pre tPA Infusion Post tPA Infusion
Pulmonary Artery Pressure 58/22 mean of 32 34/10 mean of 20
Right Atrial Pressure 3 with a negative Kussmaul
RVSP 58 with a RDEVP of 7
Wedge 15
Case Summary• Significant improvement of functional status and by
echocardiographic evaluation
• Hemodynamically stable post tPA infusion
• Improved saturation requiring no supplemental oxygen 4 days post tPA infusion
• Ambulated well with cardiac rehab services within 2 days post tPA infusion
• Discharged home on Day 14 once INR therapeutic
Conclusion•Significant risks associated with large boluses of tPA needed to resolve clot
•Drug Delivered via Guide Catheter may not be adequate for dissolution of heavy thrombus burden
•Site specific drug delivery is effective in quickly resolving pulmonary embolism with less drug utilized
•Intra-clot delivery via an atraumatic drug delivery balloon holds great promise for managing thrombus burden and improving lung function