www.mjms.usm.my © Penerbit Universiti Sains Malaysia, 2013 For permission, please email:mjms.usm@gmail.com

Case report

MrM, a 36 years old Somalianman had ahistoryofbilateralkneepainsincelatechildhood.Over the years, the pain became unbearableand the right knee joint had limited range ofmovement.Hisdaily lifeactivitieswere severelyaffected. On 14th of May 2010, he visited theorthopaedicclinic inourcenter.Theradiographoftherightkneeshowederosionofthearticularsurfaceswithreductioninjointspace.Inaddition,minimal subchondral sclerosiswaspresent.Theleft knee radiographwas less remarkablewithamild reductionof joint space,andnosignificantjoint erosion demonstrated (Figure 1a). HisC-reactive protein and uric acid levels werenormal.His serumanti-nuclear antibody (ANA)test and rheumatoid factor test were negative.Hewasdiagnosedwithseronegativerheumatoidarthritis with severe arthritic changes of therightkneejoint,andwasindicatedforrighttotalknee replacement (TKR). His pre-operativebiochemichal investigationswerewithin normalranges. Chest radiograph, electrocardiography(ECG), and cardiac ultrasound also showed no

Case Report

Submitted: 19Jun2012Accepted: 13Dec2012

Percutaneous Catheter-Based Rheolytic Thrombectomy for Massive Pulmonary Embolism: A Case Report

Dang NguyeN, Yazmin yaacob, Sobri Muda, Zahiah MohaMed

Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia

Abstract Pulmonarythromboembolismisalife-threateningcardiovascularcondition.Themortalityrateishighinitscurrentmanagement.Besidessupportivetreatments,systemicthrombolysisandsurgical thrombectomy play important roles in the comprehensive management of pulmonaryembolism(PE).Thepercutaneouscatheter-basedrheolyticthrombectomyisapromisingalternativeformanagementofmassivepulmonaryemboli,particularly,whenpatientshavecontraindicationwithsystemicthrombolysisorarenotsuitableforsurgery. Wepresentthecaseofa36-year-oldSomalianmanwhocametoourcenterforatotalkneereplacement(TKR).ThreedaysafterTKR,hedevelopedsuddenshortnessofbreathanddecreasedoxygen saturation. Computed tomography of pulmonary arteriogram showed extensive thrombiwithinthemainpulmonarytrunk,rightandleftpulmonaryarteries,bilateralascendingandbilateraldescendingpulmonaryarteriesinkeepingwithmassivePE.Becausethepatientwascontraindicatedforsystemicthrombolysis,percutaneous,catheter-basedrheolyticthrombectomywaschosenasthealternativetreatment.Hisclinicalsymptomsimprovedimmediatelypost-treatment.Inconclusion,catheter-basedrheolyticthrombectomycanserveasanalternativetreatmentformassivePEwithagoodclinicaloutcome.

Keywords: thrombectomy, thrombolysis, pulmonary embolism

significantabnormality. He underwent right TKR on 21st of May2010 (Figure 1b). The operationwas uneventfulwith an operative time of approximately threehours. Intraoperatively a limb tourniquet wasused to reduce blood loss. Surgical biopsy wasdoneandthehistopathologicalstudyoftherightkneeshowedfragmentsoffibrocollagenoustissueadmixedwithadiposetissue,andlinedbysynovialepithelium.Cellularareascomposedofhistiocyticcells and a fewmultinucleated giant cells, werenoted which formed papillary projections.Collection of hemosiderin-laden macrophageswas identified and foci of calcification werepresent.Findingswereconsistentwithpigmentedvillonodularsynovitis(PVNS). Three days after the operation, he becameprogressively tachypnoeic. His blood pressuredropped to 80 mmHg systolic with sinustachycardiaof130–140beatsperminute(bpm).Resultsofclinicalexaminationofthelungswerenegativeastherewerenocrepitations,rhonchi,orbronchialbreathsoundstosuggestatelectasisorpneumonia. The arterial blood gas (ABG) resultrevealed a decrease in oxygen saturation (88%)with decrease in carbon dioxide and oxygen

70Malays J Med Sci. Mar-May 2013; 20(2): 70-75

Case Report |Rheolyticthrombectomyformassivepulmonaryembolism

www.mjms.usm.my 71

partial pressure (PCO2 and PO2). ECG showedsinus tarchycardia with dominant R wave onleadV1.Afibrindegradationtest(D-Dimer)wasnotperformed.Thepatientthenwastransferredto the general intensive care unit (GICU) forairway and hemodynamic supports. His bloodpressure had gone up to 104/65 mmHg withfluid and inotrope infusion. The heart rate wasstabilizedto95–100bpm.Computedtomographyof pulmonary arteriography (CTPA) was doneimmediately after stabilization, and showedextensive thrombi within the main trunk, rightandleftmainpulmonaryarteriesinkeepingwithsaddleemboli(Figure2).Inaddition,therewerethrombi present in ascending, descending, andtertiarybranchesofbothpulmonaryarteries.Thelargestthrombuswasintheleftmainpulmonaryarterywhichmeasured 4.0 cm× 0.7 cm. Therewere also areas of plate atelectasis in both lung

bases. Hence, with presence of progressivehypotensive episodes and CTPA findings, thepatientwasdiagnosedwithmassivePE. A multidisciplinary discussion between theorthopaedic,cardiothoracic,andtheinterventionalradiology teams took place to determine thebest treatment option. Systemic thrombolyticor fibrinolytic treatment would compromise hisnewTKRashematomawithinthenewjointwillpre-dispose him to infection in the joint. Withregards to the open thrombectomy, because thepatient has extensive PE, which is associatedwithhighmorbidity andmortality rates,hewasconsidered a high-risk candidate for open heartsurgery.Acatheter-basedrheolyticthrombectomyperformed by the interventional radiology unitwas decided upon, as it wasminimally invasiveandhadthepotentialtoevacuatetheclots,oratleastimprovetheclinicaloutcome.

Figure 1: (1a) Pre-operative radiograph of both knees show erosion of articular surface of the rightdistal femurandproximal tibiawithreduction in jointspace(arrows).Therewasminimalsubchondral sclerosis on the right, although no osteophyte was noted. The left knee hadmildjointspacereduction;however,therewasnosignificantjointerosion.(1b)Radiographsof the right knee 3 days post-operation for total knee replacement showed in-place rightkneeprothesis.

Figure 2: 2a, 2b, 2c; Computed tomography of pulmonary arteriography (CTPA) showed extensivefillingdefectswithinthemaintrunk,rightand leftmainbranches,secondaryandtertiarybranchesofthepulmonaryarteriesrepresentingpulmonaryembolism(arrows).

72 www.mjms.usm.my

Malays J Med Sci. Mar-May 2013; 20(2): 70-75

Accesstothepulmonaryarterywasthroughtherightfemoralveinusinga6Frvascularsheath,whichwas changed to8Fr sheath subsequentlyto advocate for the thrombectomy catheter.Initial diagnostic runs were performed usinga 5 Fr pigtail catheter which revealed that thepatienthadacongenitalventricularseptaldefect(VSD) (Figure 3a). The massive saddle emboliwasconfirmedbythepresenceofmultiplefillingdefectswithinthemaintrunk,rightandleftmainpulmonaryarteriesaswellasbilateralascendingand descending pulmonary arteries (Figure 3band3c). An exchange guidewire and a guiderwere used to facilitate the 6 Fr rheolyticthrombectomy catheter to the main pulmonaryartery. This cathether, Angiojet® Xpeedior®(AngioJet; Possis Medical, Minneapolis, MN),utilized complex fluid flow patterns to captureandremovethrombus.Intravenousthrombolysiscan also be administered through this catheterwith its power pulse delivery, although itwas not administered during this treatment.Total thrombectomy time was maximum at 10minutes.Inalltimes,thepatient’scardiovascularfunction was monitored by the anaesthetists.The intraluminalbloodclotswere suckedoutatthe main trunk, right and left main pulmonarybranches, bilateral ascending and descendingpulmonary arteries. Approximately, 60% ofthe blood clots were fragmented and suckedout as being evident by the reduction in fillingdefects compared with the baseline diagnosticruns.Thesaturatedoxygen improved from88%pre-treatment to 100% after treatment usinghigh-flowoxygen.Hisbloodpressurewasstableranging from 110/70 mmHg to 128/70 mmHgwith the heart rate of 88–100 bpm. Thethrombectomywasfollowedbyinferiorvenacava(IVC)filterinsertion.Therewereclotsremainingat the left descending pulmonary artery whichcouldnotbe removeddue to technicaldifficulty(Figure3dand3e). Subsequently, the patient’s oxygensaturation level remained stable with oxygenrequirement of 3 L/min. Heparin infusion of100internationalunits(IU)perhourwasstarted36 hours after thrombectomy. Three days afterthrombectomy, the inotrope had been titratedoff as he was hemodynamically stable andthe patient was no longer showing symptomsof cardiopulmonary insufficiency thereafter.The patient’s oxgen saturation, PCO2 and PO2returned to normal ranges under room air.Concurrently, after thrombectomy he developedhematuria four hours after the treatment. This

was likely in keeping with hemoglobinuriasecondarytohaemolysis,butitwasresolvedtwodays after the thrombectomy. The patient wassupported with hydration therapy, renal profilemonitoring and arterial blood gas analysis foranyearlysignofrenalfailure. Duringhisrecoveryperiod,healsodevelopedrightmiddlelobepneumoniaandwasdiagnosedwith hospital acquired or ventilator acquiredpneumonia. The pneumonia was resolved afterseven days of antibiotics with administration of3 g Cefepime daily. Ultrasound doppler in bothlower limbs showed no evidence of deep veinthrombosis(DVT).However,wedidnotmanageto do a baseline lower limb doppler ultrasoundbefore the intravenous heparinasation. Thepatient was generally well, ambulated with amoving frame and was discharged three weekslater.Afterdischarge,hewasprescribedanoralanticoagulant(warfarin5mgdaily)andwasgivenadateforIVCfilterremovalin12weekstime.

Discussion

The case report illustrated an alternativeto the conventional treatment, which includessystemicthrombolysisandsurgicalembolectomyforthemanagementofPE. Management of acute PE remains achallenge,particularly,inthosewithconcomitantmorbidity. Mortality rate remains exceedinglyhigh(52%)inpatientswithmassivePE,althoughtheyhavebeentreatedwithsystemicfibrinolysis.Atpresent,clinicaleffectivenessofthefibrinolysison mortality has not been clearly establishedbeyond90days(1). Systemicthrombolysissuchasrecombinanttissue plasminogen activator (r-TPA) has beensuggested as the first-line treatment in patientswith high risk PE presenting with cardiogenicshock with very few contraindications (2). Onaverage,morethan90%ofpatientswillrespondto systemic thrombolysis within 36 hours (3).Good clinical outcome can be achieved if thethrombolysisisinitiatedwithin48hoursofonset(4). Systemic heparinisation is recommendedonlyafteroneweekofonsetas thebenefitsandrisks were similar to systemic thrombolysis(5,6). However, systemic thrombolysis carries asignificantriskofbleedingwhichisapproximately13% ofmajor bleeding and 1.8% of intracranialor fatal haemorrhage, particularly, when pre-disposing conditions or co-morbidities existed(5,7). Surgical pulmonary embolectomy hasbeen performed for selected patients who

Case Report |Rheolyticthrombectomyformassivepulmonaryembolism

www.mjms.usm.my 73

have contraindication or inadequate responseto thrombolysis, as well as those with patentforamen ovale and intracardiac thrombi (3).However,surgical treatmentcanonlybeofferedinthelimitedspecializedcentersaswithallopenheart surgery,mortality andmorbidity ratesarehigher,andcarefulselectionofpatientsmustbedone. Surgical embolectomy is best done beforedevelopmentofcardiogenicshock. The recent American Heart Association(AHA)guidelinesformanagementofmassiveandsubmassivePE,iliofemoraldeepveinthrombosisand chronic thromboembolic pulmonaryhypertension 2011, has recognized catheter-based interventions or percutaneous catheter-based thrombectomy (PCBT), as an alternativewhenthereiscontraindicationornoeffectivenesswith thrombolysis and when the surgery is

impractical (2,8). Moreover, this indication canextend to the patients without contraindicationof thrombolysis and those of late presentation(> 96 h after the onset) (1). Hybrid procedureswhich are mechanical thrombectomy as well aspharmacologicaladministrationofthrombolyticsappeartobethebestoptioninmanagingmassivePE.AHAcategorisedcatheter-basedinterventionsaslevelC,classIIA,recommendationssincethereis no randomized trial of medical managementversus catheter-based interventions that exist.Catheter-based interventions should be madean option in the presence of local expertise andavailabilityofdevicesandfacilities(8). PCBT has presented clear advantagescompared with other treatments. Firstly, thethrombusisremovedbyananatomicallylocalizedtherapy. Intra pulmonary thrombolysis can be

Figure 3: (a) The catheter’s tip was identified within the left ventricle and contrast flows directlyintotheascendingaorta.(b,c)Thesewereconsistentwithventricularseptaldefect.Pulmonaryarteriogramshowedmultiplefillingdefectswithinthepulmonaryarteries(whiteshortandblacklongarrows).(d,e)Post-thrombectomypulmonaryarteriogramshowedresidualfillingdefectswithin the left descending pulmonary artery (white short and black long arrows).Therestofthepulmonaryarterieswerepatent.

74 www.mjms.usm.my

Malays J Med Sci. Mar-May 2013; 20(2): 70-75

addedifconsiderednecessaryandassumedthatit does not induce systematic fibrinolytic state.Secondly,theguidingcathetercanbesteeredintothe affected territories with selective aspiration.Recovery of the flow can be ascertained duringthe procedure, and the pulmonary pressure iscontinuously monitored. Thirdly, PCBT canbe performed immediately after the diagnosticpulmonary angiogram meanwhile it takes timeforthrombolysistobeeffective(1). ThemechanismoftheAngioJet®Xpeedior®Catheter involvesusingpositivepressure for thesaline spray, and negative pressure to suck theclotsusingtheBernoulliprinciple.Thespecializedcatheter with multiple holes has functions forsalineanddrugsprayingandalsoforsucking.Thehigh pressure saline streams spray to break thethrombus,afterwhichtheclotfragmentswillbesucked away. The sprayswillmake the catheterstay apart from the vessel wall, decreasing theincidence of arterial denudation. Fragmentedthrombuswillbecollectedinabagattachedtothesuctiondevice(9). Complications inPCBT includearrhythmia,particularly,bradycardia,tricuspidregurgitation,mechanical hemolysis, fluid overload, andbleedingduetoanticoagulation.Moreover,injurytothestructuresincludingventricularperforationanddenudationof the intimate layerwas morelikelytooccurifcathetersizesarebig(10French(F) ormore). Reducing the procedure time andusing short, intermittent pulsation in additionto using smaller catheters can reduce this risk(1,2,10). Inourcase, thepatienthada transienthemoglobinuriaduetoclotfragmentation. OurpatienthadmassivePEwith thrombuswithin the main trunk, right and left mainbranches, ascending and descending as well asthe tertiary branches of pulmonary arteries. Hewas classified as grade 4 PE since more than50% of pulmonary arteries were thrombosed(11). ECG showed prominent R wave at leadV1, representing pulmonary hypertension dueto PE with contribution from VSD. At the timeof diagnosis, the patient had hypotension withshockindex>1.However,thesignsofcardiogenicshockdidnotprogressfurtherpartiallysincethediagnosiswasmadeearly,andthetreatmentwasinitiated instantly before outbreak of the moreseveresymptoms.Heshowedimmediateclinicalimprovement after thrombectomy with goodresponsetothetreatment. Thereweremanysmallstudies,whichshowedsuccess with PCBT with or without localizedthrombolytics with minimal complication and

good efficacy (1,12,13). One common thingthat these studies shared was that PCBT was atreatmentoptiononlywhensystemicthrombolysiswas contraindicated.Withmore studies comingup, PCBT should be considered as the first-linetreatment formassivePEas it canprovidebothmechanicalandpharmacological treatment.It isafocusedtherapythatisminimallyinvasivewithminimalcomplication.

Conclusion

Asillustratedinthiscase,thrombectomycanbecomeanalternative treatment formassivePEwithrelativelygoodclinicaloutcomewhenthereis contraindication for systemic fibrinolytics.Interventional radiologists or endovascularspecialists who are experts in operatingthrombectomy devices should be the ones whoperformcatheter-basedinterventionsinPEwiththehelpofcardiopulmonaryanaesthetists.

Acknowledgement

Enago (www.enago.com) for the Englishlanguage review and MJMS editors for theireditingthepaper.

Conflict of interest

Noconflictionofinterest.

Funds

I wish to extendmy gratefulness to Dr Yazminforherfundfortheproofreadservice.

Authors’ Contribution

Conceptionanddesign,analysisandinterpretationofthedata,draftingofthearticle,andcollectionandassemblyofdata:DVNCritical revision of the article for importantintellectualcontent:YY,SM,ZM

Correspondence

DrDangNguyenMD(CTUMP),MmedRad(UKM)DepartmentofRadiologyUniversitiKebangsaanMalaysiaMedicalCentreJalanYa’acobLatif,BandarTunRazak56000Cheras,KualaLumpurTel:+60173165496Fax:+60391737824E-mail:dangnguyen094@gmail.com

Case Report |Rheolyticthrombectomyformassivepulmonaryembolism

www.mjms.usm.my 75

References

1. Arzamendi D, Bilodeau L, Ibrahim R, Noble S,Gallo R, Lavoie-L’allier P, et al. Role of rheolyticthrombectomyinmassivepulmonaryembolismwithcontraindication to systemic thrombolytic therapy.Eur Interv.2010;5(6):716–721.

2. Torbicki A, Perrier A, Konstantinides S, Agnelli G,Galie N, Pruszczyk P, et al. Guideline on diagnosisandmanagementofacutepulmonaryembolism:theTask Force for the Diagnosis and Management ofAcutePulmonaryEmbolismoftheEuropeanSocietyofCardiology.Eur Heart J.2008;29(18):2276–2315.doi:10.1093/eurheartj/ehn310.

3. Meneveau N, Seronde MF, Blonde MC, LegaleryP, Didier-Petit K, Briand F, et al. Managementof unsuccessful thrombolysis in acute massivepulmonary embolism. Chest . 2006;129(4) :1043–1050.

4. LyB,ArnesenH,EieH,HolR.Acontrolledclinicaltrial of streptokinase and heparin in the treatmentof major pulmonary embolism. Acta Med Scand.1978;203(6):465–470.

5. Bell WR, Simon TL, Stengle JM, Sherry S. Theurokinase-streptokinase pulmonary embolismtrial (Phase II) results. Urokinase-StreptokinasePulmonaryEmbolismTrialStudyGroup.Circulation.1974;50:1070–1071.doi:10.1161/01.CIR.50.6.1070.

6. KonstantinidesS,TiedeN,GeibelA,OlschewskiM,Just H, Kasper W. Comparison of alteplase versusheparinforresolutionofmajorpulmonaryembolism.Am J Cardiol.1998;82(8):966–970.

7. Dalla-VoltaS,PallaA,SantolicandroA, GiuntiniC,PengoV,VisioliO,etal.PAIMS2:alteplasecombinedwith heparin versus heparin in the treatment ofacute pulmonary embolism. Plasminogen activatorItalian multicenter study 2. J Am Coll Cardiol. 1992;20(3):520–526.

8. Jaff MR, McMurtry MS, Archer SL, Cushman M,Goldenberg N, Goldhaber SZ, et al. Managementof Massive and Submassive Pulmonary Embolism,Iliofemoral Deep Vein Thrombosis, and ChronicThromboembolic Pulmonary Hypertension: AScientific Statement From the American HeartAssociation. Circulation. 2011;123(16):1788–1830.doi:10.1161/CIR.0b013e318214914f.

9. Clinical policy bulletin: angiojet rheolyticthrombectomysystem[Internet].Aetna;2001[cited2012 May 20]. Available from http://www.aetna.com/cpb/medical/data/500_599/0568.html.

10. Skaf E, Beemath A, Siddiqui T, Janjua M, PatelNR, Stein PD. Catheter tip embolectomy in themanagement of the acute massive pulmonaryembolism. Am J Cardiol.2007;99(3):415–420.

11. Dahnert W. Thromboembolism. In: Mitchell CW,editor.Radiological review manual. 6th ed.UnitedStates(US):LippincottWilliam&Wilkins;2008.p.523–526.

12. Suarez JA, Meyerose GE, Phisitkul S, Kenedy S,RoongsritongC,TsikourisJ,etal.Reviewofcatheterthrombectomy devices. Cardiology. 2004;102(1):11–15.

13. Zeni PT, Blank BG, Peeler DW. Use of rheolyticthrombectomy in treatment of acute massivepulmonary embolism. J Vasc Jnterv Radiol. 2003;14(12):1511–1515.