Pulmonary embolism is the third most frequent cardiovascular pathology, with an incidence of 100-200 cases for 100.000 inhabitants and is one of the main causes of mortality, morbidity and hospitalizations. Systematic thrombolysis represents the treatment of first choice in high-risk/high-intermediate-risk patients who experience hemodynamic instability, however there are absolute and relative contraindications that do not allow its use in all patients: in these cases, percutaneous catheter treatment can be attempted.
A hypertensive and obese 84-year-old woman arrives at the emergency room with the onset of chest pain associated with dyspnea. In the emergency room, high levels of D-Dimer and highly sensitive Troponin T are found, therefore cardiological advice is requested. The echocardiogram shows severe dilatation of the right ventricle with McConnel sign, D-Shape and multiple thrombotic formations in the right atrium. On the advice of the consultant cardiologist, a pulmonary CT angiography is performed with evidence of thromboembolism of the main arterial trunks, massive at the level of the distal juxta-hilar portions. Therefore, high-intermediate-high risk pulmonary embolism is diagnosed and the patient is transferred to the ICU for proper treatment.
Despite the infusion therapy with sodium heparin, there is a sudden worsening of the clinical and hemodynamic picture: thus, in the light of the impossibility of performing a rescue thrombolysis due to the recent patient’s femoral fracture, it is decided to perform a percutaneous treatment by thrombectomy, using an “INARI” thrombus-aspirator catheter positioned to the right femoral route. Pulmonary angiography reveals thrombotic sub-occlusion of booth main branches. Five aspiration cycles are performed, two of which in the right pulmonary artery and the remaining three in the left pulmonary artery. Control angiography shows reperfusion of the left lower lobe and partial reperfusion of the left upper lobe, while partial reperfusion of the right upper lobe is found on the right. Abundant thrombotic and partly fibrous material is found during aspiration. After the 5th cycle, cardio-circulatory arrest occurs and despite the resuscitation maneuvers, the patient dies. At present, percutaneous treatment in acute pulmonary embolism is still scarcely used in daily clinical practice, but it will certainly play an important role in the near future as a valid therapeutic alternative