Catheter-Assisted Pulmonary Embolectomy

Case presentation : A 65-year-old man presented to the emergency department after a fall and was diagnosed with a fracture of the right femoral neck. He was scheduled for surgical repair the following day. During positioning for arthroplasty, he developed hypotension, tachycardia, and hypoxia, followed by pulseless electric activity. He was resuscitated and maintained on epinephrine and norepinephrine infusions. A transesophageal echocardiogram revealed a dilated and hypokinetic right ventricle with preserved apical contractility (Figure 1). Massive pulmonary embolism (PE) was suspected. What are the therapeutic options for this critically ill patient?Figure 1. A , A dilated and hypokinetic right ventricle (arrow) is seen on a transesophageal echocardiogram. B , The interatrial septum (arrow) is bulging into the left atrium, suggesting increased right atrial pressure. C , A D-shaped interventricular septum (arrow) is caused by pressure and volume overload of the failing right ventricle. RV indicates right ventricle; LV, left ventricle.Patients afflicted with massive PE have 90-day mortality rates approaching 50%.1 Massive PE is defined by sustained hypotension (systolic blood pressure <90 mm Hg for a minimum of 15 minutes, or requirement for inotropic support), pulselessness, or bradycardia with signs of shock.2 As many as 10% of patients with submassive PE can develop hemodynamically significant and life-threatening right ventricular failure.3 In such cases, supportive care and anticoagulation must be accompanied by rapid reduction of right ventricular (RV) afterload and restoration of adequate cardiac output. Many patients with submassive PE and stable blood pressure develop residual RV dysfunction and experience a decline in functional status at 6-month follow-up. Acute relief of RV strain and reduction of thrombotic burden in the pulmonary arteries could yield long-term benefit in this group.4Pharmacological and invasive strategies for reduction of thrombotic burden in the pulmonary arteries have been used for many decades …