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• W2103299282 abstract "Editor: Recently, thrombectomy and thrombolysis as a means of resuscitation in life-threatening pulmonary embolism (PE) have been used with success (1Arcasoy SM Kreit JW Thrombolytic therapy of pulmonary embolism: a comprehensive review of current evidence.Chest. 1998; 115: 1695-1705Crossref Scopus (217) Google Scholar, 2Tai NRM Atwal AS Hamilton G Modern management of pulmonary embolism.Br J Surg. 1999; 86: 853-868Crossref PubMed Scopus (32) Google Scholar, 3Gray HH Miller GAH Paneth M Pulmonary embolectomy: its place in the management of pulmonary embolism.Lancet. 1988; 1: 1441-1445Abstract PubMed Scopus (48) Google Scholar, 4Uflacker R Interventional therapy for pulmonary embolism.J Vasc Interv Radiol. 2001; 12: 147-164Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar). We report a case of massive life-threatening PE in early pregnancy that was percutaneously managed with a combination of mechanical thrombectomy and local thrombolysis with recombinant tissue plasminogen activator (rt-PA; Activase, Altepase recombinant; Genentech, South San Francisco, CA). This treatment saved the mother's life, but the 15-week embryo was unfortunately spontaneously aborted 24 hours after the termination of the thrombolytic therapy. A 19-year-old woman in her 15th week of gestation presented to the emergency department complaining of sudden onset of dyspnea that awoke her from sleep. Physical and laboratory evaluation including transthoracic echocardiography demonstrated severe hypoxia and hypercarbia and right ventricular strain consistent with the diagnosis of acute PE. Abdominal ultrasonography (US) confirmed the presence of a live fetus at 15 weeks of gestational age. Contrast enhanced helical computed tomographic (CT) examination of the chest confirmed the presence of thrombus in the common, left, and right pulmonary arteries (Fig 1). While the patient was treated in the medical intensive care unit with intravenous heparin, she experienced worsening dyspnea and hemoptysis requiring emergent intubation. A follow-up CT scan of the chest revealed no significant change of the saddle embolus but progression of bilateral lower lobe consolidation, interpreted as pulmonary infarcts. Transthoracic echocardiography was repeated, revealing persistent right ventricular dilation. A multidisciplinary evaluation by the obstetric and gynecologic, cardiothoracic surgery, interventional radiology, and medicine services recommended a percutaneous approach by the interventional service as the patient's best option (4Uflacker R Interventional therapy for pulmonary embolism.J Vasc Interv Radiol. 2001; 12: 147-164Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar). A surgical approach at that time was considered too risky for the mother. By the right common femoral venous approach, the patient underwent pulmonary arteriography that displayed massive PE involving the common, right, and left pulmonary arteries (Fig 2). Initial balloon embolectomy (11.5-mm Standard Occlusion Balloon; Boston Scientific/Medi-tech, Watertown, MA) was performed in the common, right, and left pulmonary arteries. The balloon was hand-inflated in the pulmonary artery and then retracted in a 90-cm-long, 8-F introducer sheath (Shuttle introducer sheath; Cook, Bloomington, IN), the tip of which was kept in the main pulmonary artery. This resulted in clot fragmentation and removal of fragments via the sheath outside the patient's body. Postembolectomy pulmonary arteriography did not reveal significant change in lung perfusion. Subsequently, an overthe-wire 6-F Oasis mechanical thrombectomy device (Boston Scientific/Meditech) was used in the common and right pulmonary artery. The device was repeatedly used with no immediate angiographic evidence of thrombus disruption or removal. Therefore, the decision was made to use rt-PA in the attempt to save the mother's life. Initially, a pulse–spray infusion of 10 mg rt-PA was instilled in the right pulmonary artery via a multi–side-hole catheter (Mewissen Infusion Catheter, Boston Scientific/Medi-tech). Improvement in flow to the distal pulmonary arteries was noted. The rt-PA infusion was continued locally in the pulmonary arteries for the next 12 hours at a rate of 2 mg/h. The patient's clinical condition improved and required less pressure support. Therefore, rt-PA infusion was terminated. Twenty-four hours later, the patient began to experience hypotension and her hemoglobin level dropped by 2 g. At that time, transabdominal and transvaginal US were performed, which showed no detectable fetal heart rate, consistent with intrauterine fetal demise. The patient's clinical condition further improved over the next 2 days and evacuation of the nonviable fetus was performed. Repeat CT demonstrated that the previously detected thrombus in the main pulmonary artery was no longer present (Fig 3). During the following week, the patient's clinical condition improved and she was extubated. Doppler US showed no evidence of deep venous thrombosis, so inferior vena cava filter interruption was not performed. She was discharged home in good condition 22 days after admission.Figure 3Post-thrombolysis CT angiogram demonstrates resolution of the pulmonary artery emboli and residual bibasilar consolidation.View Large Image Figure ViewerDownload (PPT) The management of pulmonary embolism during pregnancy (a well recognized risk factor) has always been clinically and ethically difficult. It raises many questions involving the well-being of the fetus and the mother as well as the possible risks related to different therapeutic options. Percutaneous thrombectomy appears to be a very attractive mode of treatment, especially in early pregnancy, when the fetus' risk from systemic thrombolysis is high (2Tai NRM Atwal AS Hamilton G Modern management of pulmonary embolism.Br J Surg. 1999; 86: 853-868Crossref PubMed Scopus (32) Google Scholar, 3Gray HH Miller GAH Paneth M Pulmonary embolectomy: its place in the management of pulmonary embolism.Lancet. 1988; 1: 1441-1445Abstract PubMed Scopus (48) Google Scholar). In view of the desire of the mother and her family for us to maximize efforts in our attempt to save her life, and understanding the imminent direct high risk to the fetus' life, we decided to initiate rt-PA thrombolytic therapy when no definite lung perfusion improvement could be seen after mechanical thrombectomy. The fact that the fetus was too young to sustain life on its own if cesarean section was attempted facilitated this decision. Fetal demise, noted 24 hours after the termination of the local infusion, was probably not caused by the toxic effect of rt-PA thrombolysis, because the agent was administered locally and, theoretically, should be metabolized before reaching the placenta and the embryo (4Uflacker R Interventional therapy for pulmonary embolism.J Vasc Interv Radiol. 2001; 12: 147-164Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar). In addition, to our knowledge, there is no research data on the effects of rt-PA on the fetus. The severe stress placed on the pregnancy secondary to the patient's massive PE certainly had its own deleterious effect on the fetus. We believe that rt-PA thrombolysis saved the mother and was probably the most effective and safe treatment option in this clinical scenario. In conclusion, life-threatening PR in early pregnancy constitutes a major therapeutic and ethical challenge. Therapy should aim at saving the mother, keeping in mind her own wishes as well as those of her family." @default.
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• W2103299282 date "2001-11-01" @default.
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• W2103299282 title "Percutaneous Management of Life-threatening Pulmonary Embolism Complicating Early Pregnancy" @default.
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