Catheter-directed thrombolysis of massive pulmonary embolism in high risk bleeding patients (local experience in kenya, single centre study)
Authors: Mohamed A , Maraka P , Gaballa M 
Published: January 2025

Abstract

Background
Pulmonary Embolism (PE) is the third most common cause of death after myocardial infarction (MI), and cerebrovascular accidents (CVA) (1). For patients who are at risk of major bleeding such as advanced age, recent operation or delivery or major trauma, strategies to minimise bleeding risk should be considered, including catheter directed thrombolysis therapy (2) in reduced dose.
Death from massive PE often occurs within the first two hours, and the risk remains elevated for up to 72 hours after presentation (3,4). Thirty-day survival following the diagnosis of a PE is only estimated to be 59.1%, and despite advances in medical care, in-hospital mortality from acute PE has remained stable over the past decade (5).
Catheter directed thrombolysis (CDT) is a novel treatment option for massive/sub massive pulmonary embolism as systemic thrombolysis for acute PE carries up to 20% risk of major bleeding, including 2-5% risk of hemorrhagic stroke (6).

Purpose
To determine the clinical outcomes of catheter directed thrombolysis in patients with massive/ sub massive pulmonary embolism.

Methods
We conducted a retrospective quantitative study of 15 patients who presented with massive pulmonary embolism. A systematic random sampling was done to select the patients at advanced age, recent operation or first 2 weeks post labour with high bleeding risk, clinical data was recorded. All patients were taken to Cath lab with right heart catheterization, RA, RV and PA pressure were measured. Swan-Ganz catheter were placed in the main pulmonary trunk in case of bilateral PE, or sub-selective in the culprit branch. Alteplase infusion was given for 24-72 hours until proof for significant lysis of the clot.
Clinical success defined as: 1. Stabilization of hemodynamics 2. Improvement in pulmonary systolic pressures, D-Dimer, TAPSE, RV/LV ratio and repeat CT findings 3. Survival to hospital discharge 4. Improvement in 30-day morbidity and mortality.

Results
There were no death on the trial group at discharge or at 30 days follow up. There were significant improvement of RV size and function elucidated by improvement of RV/LV ratio which were reduced from 1.06±0.18 to 0.89±0.2, TAPSE increased from 14.07±1.6 to 17.6±2.2, p &lt; 0.01. There was significant drop in systolic pulmonary pressure(sPA) 67±14.5 mmHg to 38±14.5mmHg, p&lt;0.001. The improvement of RV function and reduced sPA pressure were associated with increase in D-Dimer by at least 35% post thrombolysis, p&lt;0.001.

Conclusion
Catheter directed thrombolysis (CDT) improves clinical outcomes in patients with acute pulmonary embolism with minimal risk of minor bleeding, and rapid recovery of right ventricular dysfunction. There were no major bleeding or death noticed in the treatment group and at one month follow up. In experienced centres, CDT is a safe and an effective treatment for both massive and/ or submassive PE.
Echocardiography findings before CDT
Echocardiography findings after CDT