Author + information
- Received March 28, 2017
- Revision received May 1, 2017
- Accepted May 4, 2017
- Published online July 17, 2017.
- Andrew Boshara, MDa,∗ (, )
- Sushruth Edla, MDb,
- Saroj Neupane, MDb,
- Howard Rosman, MDb and
- Antonious Attallah, MDb
- aDepartment of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan
- bDepartment of Cardiology, St. John Hospital and Medical Center, Detroit, Michigan
- ↵∗Address for correspondence:
Dr. Andrew Boshara, St. John Hospital and Medical Center, 22101 Moross Road, Detroit, Michigan 48236.
Pulmonary emboli (PE) in transit are associated with high mortality (27%) (1). Current treatment modalities have not been studied in randomized trials and carry exorbitant risks (2). We encountered a 78-year-old man with a history of gallbladder cancer who presented after a ventricular fibrillation arrest. On arrival, he was normotensive, tachycardic, and tachypneic. Computed tomography angiogram of the chest demonstrated bilateral upper and lower lobe pulmonary emboli (Figure 1A) and a right ventricle (RV) to left ventricle (LV) diameter ratio ≥0.90 (Figure 1B). Unfractionated heparin was initiated with an intravenous bolus dose of 80 international units/kg followed by infusion with a targeted activated partial thromboplastin time of 1.5 to 2 times the laboratory control. Transthoracic echocardiogram (TTE) revealed a highly mobile thrombus in transit, occupying a large area within the right atrium (RA) (Figure 2A, Online Video 1). Consequently, the patient underwent ultrasound-assisted catheter-directed thrombolysis (USAT) using the Ekosonic endovascular system (EKOS, Bothell, Washington). Pulmonary angiogram was performed to enable accurate catheter insertion (Figure 3A). The USAT catheters were inserted bilaterally extending up to the right and left pulmonary artery bifurcations (Figure 4) and left in place to infuse tPA at 1 mg/h/catheter for 12 h. Catheters were then removed and angiogram was performed again (Figure 3B), which revealed improvement in pulmonary hemodynamics and perfusion of previously oligemiclobes. TTE performed 48 h post-USAT demonstrated near-complete resolution of the RA thrombus (Figure 2B, Online Video 2). The patient was discharged on enoxaparin to an extended-care facility. These promising results suggest that USAT could be a beneficial tool in the treatment of PE in transit.
For supplemental videos and their legends, please see the online version of this article.
Dr. Attallah is a faculty instructor for Cardiovascular Systems Incorporated (CSI). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 28, 2017.
- Revision received May 1, 2017.
- Accepted May 4, 2017.
- 2017 American College of Cardiology Foundation