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

Disclosures

• None

• $265,000 USD in medical school loans

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

Thank you!