VCOM Louisiana Research Day Program Book 2024

Clinical Research

Anish Patel, BS, OMS-III VCOM-Louisiana; Willis-Knighton Pierremont Medical Center 33 A CASE OF CATHETER-DIRECTED THROMBOLYSIS AND THROMBECTOMY USING THE PENUMBRA INDIGO SYSTEM

Background: Pulmonary embolism is a serious complication of thromboembolic disease that can be a significant cause of mortality in patients. Thus, it is important to consider advancements in the treatment methods in patients with pulmonary embolism as well as the underlying cause. This case report will discuss a 77-year-old female that presented to the emergency department with a 2-day history of shortness of breath, cough, and tachycardia. Imaging workup revealed that the patient had bilateral pulmonary emboli with right sided heart strain. The patient underwent pulmonary artery thrombectomy with the Penumbra Lighting Flash device which led to resolution of her symptoms. This case highlights the importance of exploring new innovations of treating pulmonary embolism with interventional techniques, as well as highlighting the need of further studies in the form of random clinical trials to determine the role interventional techniques have on reducing morbidity and mortality. Results: Once a PE is confirmed in a patient, it is beneficial to further risk stratify the severity of the PE based on clinical findings. The severity of the PE helps determine which patients are better candidates for interventional therapy. Clinical parameters that indicate higher risk for early death from a PE are hemodynamic

instability, right ventricular dysfunction, elevated plasma levels of cardiac troponins, and other comorbidities [3]. The levels of risk are defined according to their respective clinical parameters in Figure C. Patients determined to have low risk or intermediate-low risk can be managed with anticoagulation. In cases where patients are clinically deteriorating (increased respiratory rate, increased heart rate, low blood pressure, increasing plasma lactate level, and signs of shock), interventional therapy or lysis is considered. In cases with high risk of early death, lysis should be started immediately unless it is contraindicated. Interventional therapy is reserved for these cases. The task of determining early death risk is complex and usually requires a multidisciplinary team, referred to as a PE response team, that consists of cardiologists, radiologists, pulmonologists, interventionalists, and intensivists. A large part of discussion that needs further study is the effect of catheter directed thrombolysis (CDT) on the morbidity and mortality of PE through randomized clinical trials (RCT). There have been limited RCT studies done on certain devices used for CDT versus anticoagulation and ultrasound-assisted catheter-directed thrombolysis, but the results are not statistically significant as they had small

sample sizes. Results from a meta-analysis that compromised of 11,932 patients with high risk or intermediate-high risk PE showed a significant reduced in-hospital mortality when catheter directed thrombolysis was used over systemic fibrinolysis (relative risk 0.52, 95% CI 0.40-0.68, P < 0.001) [3]. Overall, larger RCT studies are needed to determine the full benefit of CDT for PE treatment. Such studies are currently planned or are in progress. Conclusions: The presented case report discusses the importance of diagnosing pulmonary embolism as well understanding the role that risk stratifying the severity of this pathology plays on clinical management. Due to the relatively nonspecific symptoms that PE has, a high clinical suspicion must be maintained when patients present with PE symptoms. In this case, PE was secondary to a possible undiagnosed thrombophilia. This case demonstrates that determining the cause of PE is crucial to prevent subsequent disease progression that can result in unfavorable outcomes. As catheter directed thrombolysis becomes the mainstay of treatment for intermediate-high- and high risk PE, larger RCT studies are needed to understand the full depth of improvement they have on the morbidity and mortality of PE.

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