Mechanical fragmentation and pharmacologic thrombolysis in massive pulmonary embolism

PURPOSE: To evaluate the usefulness of mechanical fragmentation associated with intrapulmonary thrombolysis in acute massive pulmonary embolism (PE). PATIENTS AND METHODS: Sixteen cases of massive PE treated with mechanical fragmentation associated with pharmacologic thrombolysis were retrospectively studied. Severity of PE was assessed with the angiographic index according to the Urokinase Pulmonary Embolism Trial (maximum value of 18; score according to whether obstruction was central or peripheral, complete or partial). Mechanical fragmentation of the emboli was performed with angiographic catheters and angioplasty balloons, Urokinase was infused directly into the thrombus during the course of 8-24 hours. The effect of therapy was measured with direct pulmonary artery pressure (PAP) and blood O-2 values. RESULTS: Pre- and postinfusion ansographic index mean values (+/- standard deviation) were 13.7 +/- 1.4 and 6.1 +/- 2.2 (P <.0001). Mean pre- and postinfusion PAPs were 48.2 +/- 13.4 and 18.5 +/- 7.2 mm Hg (P <.0001). PaO2 increased from 60.1 +/- 12.1 to 88.7 +/- 23.4 mm Hg (P =.01). Fourteen patients (87.5%) completely recovered. One patient died during treatment despite improvement in PAP and PaO2 parameters. There were no major hemorrhagic complications. CONCLUSIONS: The data support the efficacy of mechanical fragmentation associated with pharmacologic thrombolysis in the treatment of acute massive PE, resulting in improved hemodynamics and blood oxygenation and in decreased PAP, with low morbidity.