AngioJet Rheolytic Thrombectomy Versus Local Intrapulmonary Thrombolysis in Massive Pulmonary Embolism: A Retrospective Data Analysis

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J ENDOVASC THER 2005;12:206–214

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INVESTIGATION

AngioJet Rheolytic Thrombectomy Versus Local Intrapulmonary Thrombolysis in Massive Pulmonary Embolism: A Retrospective Data Analysis Dimitris Siablis, PhD1; Dimitris Karnabatidis, PhD1; Konstantinos Katsanos, MD1; George C. Kagadis, PhD2; Peter Zabakis, MD1; and George Hahalis, PhD3 Departments of 1Radiology and 3Cardiology, University Hospital of Patras, and 2Department of Medical Physics, University of Patras, Rion, Greece. l

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Purpose: To compare the efficacy of full-dose local intrapulmonary thrombolysis (LIT) versus AngioJet rheolytic thrombectomy (ART) in the treatment of massive pulmonary embolism. Methods: A retrospective review was conducted of 8 consecutive patients (5 women; mean age 66.065.9 years, range 56–74) who underwent LIT with high-dose intrapulmonary urokinase (4400 IU/kg over 10 minutes followed by a 2000-IU/kg/h infusion) and a subsequent 6 consecutive patients (4 men; mean age of 59.2617.0 years, range 26–69) who underwent ART plus adjunctive low-dose urokinase infusions (100,000 IU) until hemodynamic recovery was achieved. Pre and postprocedural Miller scores were calculated, and relative Miller score improvement, total urokinase doses, and duration of therapy were compared. Results: Hemodynamic stability was restored in all 8 LIT patients and in 5 (83%) of the 6 ART patients; 1 (16.7%) patient died during the ART procedure due to recurrent MPE. In the LIT group, the mean Miller score prior to intervention was 17.3862.67, which was reduced to 6.1361.46 after the intervention (p,0.0001) compared to scores of 18.8362.86 and 6.8362.79, respectively, in the ART group (p,0.0001). The mean urokinase dose was 2.0760.44 million IU in the LIT group versus 0.7060.36 million IU in the ART group (p,0.0001). The mean duration of therapy was 11.4562.94 hours in the LIT group versus 3.3761.41 hours in the ART group (p,0.0001). No significant difference in relative Miller score improvement was observed. Conclusion: By accelerating the fragmentation of thrombus, ART plus adjunctive low-dose urokinase seems to be more rapidly effective compared to LIT. ART achieves both rapid cardiovascular relief and reduces the dose of thrombolytic agent necessary in patients with massive pulmonary embolism. J Endovasc Ther 2005;12:206–214 Key words: pulmonary embolism, thrombolysis, rheolytic thrombectomy, urokinase l

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Despite advancements in modern therapeutics, pulmonary embolism (PE) still presents a therapeutic challenge for physicians, with causes ranging from clinically trivial thromboembolic disease to potentially lethal mas-

sive pulmonary embolism (MPE), in which .50% of a pulmonary artery is occluded. The International Cooperative Pulmonary Embolism Registry of 2454 patients demonstrated an 11% mortality rate at 1 hour after symptom

Address for correspondence and reprints: Dimitris Siablis, Associate Professor, Department of Radiology, Angiography Suite, University Hospital of Patras, GR 26500 Rion, Greece. Fax: 30-2610-993445; E-mail: [email protected] Q 2005 by the INTERNATIONAL SOCIETY

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ENDOVASCULAR SPECIALISTS

Available at www.jevt.org

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presentation and an overall 17.4% mortality within 3 months.1 With coexistent hemodynamic impairment, the in-hospital mortality rises to 31%, according to the Management Strategies and Determinants of Outcome in Acute Pulmonary Embolism Trial.2 Thus, in almost two thirds of the cases, the patients will die within the first 1 hour,3,4 and of those, anatomical MPE accounts for half of the deaths.3–5 Kenneth E. Wood6 called this the ‘‘Golden Hour’’ of hemodynamically significant PE in which a rapidly effective therapeutic approach should focus on hemodynamic decompensation. Unfractionated or low-molecular-weight heparin, which forms the foundation of conservative treatment of hemodynamically stable PE, averts additional thrombus formation and allows endogenous fibrinolysis and fibrinogenolysis to gradually dissolute the clot. However, in MPE, the high mortality rate and the limited time available for intervention have obliged physicians to endorse more aggressive tactics. Thrombolytic agents are indicated for patients in shock and those with hypotension or with other evidence of systemic hypoperfusion attributed to MPE,7 but this approach has not been proven to reduce mortality or the risk of recurrent PE in hemodynamically stable patients.8,9 Moreover, the need for expeditious therapeutic management and the evolution of sophisticated interventional instruments have led to new interventional techniques for the treatment of submassive and massive PE. Transvenous pulmonary embolectomy was first performed with a 10-F steerable aspiration catheter by Greenfield et al.10 in 1971. In the last decade, however, novel mechanical and rheolytic thrombectomy procedures have evolved.11–16 Today, percutaneous clot fragmentation and aspiration techniques are available to treat unstable patients in shock or with other signs of systemic hypoperfusion who are not candidates for pharmacological thrombolysis or surgical embolectomy.17 Having amassed clinical experience with rheolytic thrombectomy in the recanalization of thrombosed arteriovenous access conduits and peripheral arteries, we began in 2000 to use this technique to treat MPE in order to improve and expedite management of these

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critical patients. The aim of this retrospective analysis was to compare the efficacy we achieved with rheolytic thrombectomy versus our antecedent high-dose protocol for local intrapulmonary thrombolysis in the treatment of MPE.

METHODS Review Parameters and Patient Population Medical charts from 1997 to 2003 were retrospectively reviewed to identify all patients referred to the angiography suite of our institution for interventional treatment of acute MPE, which was defined as PE with hemodynamic impairment resulting from the interaction of embolus size and underlying cardiopulmonary status, irrespective of angiographic obstruction scores.6 Suspicion of PE was initially raised by the medical history, the physical examination, and the 12-lead electrocardiogram. After bedside duplex sonography or pelvic venography excluded iliofemoral thrombosis and precluded potential iatrogenic sources of further embolism, lung perfusion scintigraphy or thoracic computed tomographic angiography (CTA) was performed. Patients with (1) a high probability perfusion scan or direct visualization of lobar/segmental thromboemboli in the pulmonary arterial vasculature and (2) right ventricular dysfunction and/or thrombus in the right heart or the pulmonary arteries on transthoracic and/or transesophageal echocardiography underwent immediate conventional pulmonary angiography. A 6-F sheath was placed in a common femoral vein, and a 5-F angled pigtail catheter was meticulously advanced through the tricuspid and pulmonary valves up to the main pulmonary artery, where digital subtraction arteriography (DSA) was performed with 15-mL/s contrast injection at 600 psi (total of 30 mL nonionic low osmolar contrast medium). Central vascular obstruction and peripheral perfusion defects were rated angiographically according to Miller et al.18 Briefly, central obstruction of the right or left lung scored 9 and 7 points, respectively, while peripheral perfusion was assessed at the upper, middle, and lower area

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of each lung (no flow: 3, severely reduced flow: 2, moderately reduced flow: 1, normal perfusion: 0). The sum of the individual scores gave the MS, which has a maximum of 34, signifying complete vascular obstruction. A diagnosis of MPE was confirmed with an MS .10.18 From January 1997 to June 2000, 8 consecutive patients (5 women; mean age 66.065.9 years, range 56–74) with acute MPE according to these criteria were treated with local intrapulmonary thrombolysis (LIT group). From June 2000 to December 2003, 6 consecutive patients (4 men; mean age of 59.2617.0 years, range 26–69) underwent AngioJet (Possis Medical, Minneapolis, MN, USA) rheolytic thrombectomy (ART group) plus adjunctive low-dose urokinase infusion. In the ART group, informed consent was obtained from the patients’ relatives because treatment involved off-label use of the AngioJet thrombectomy device in the pulmonary bed; for ethical reasons, thrombolysis was never completely withheld in the ART group, unless contraindicated, and the adjunctive urokinase dosage was dictated by the clinical course. All patients were either hospitalized or admitted in the emergency department as a result of a diverse, usually severe, symptomatology. Complaints ranged from acute chest pain to dyspnea or episodes of syncope. All patients had associated predisposing factors for PE. Deep vein thrombosis (DVT) was present in 64% (n59); 57% (n58) were heavy smokers, and 36% (n55) had undergone orthopedic surgery. Postmenopausal hormone replacement therapy had been prescribed in one woman. One young man was diagnosed with idiopathic antiphospholipid syndrome. However, hypercoagulability tests, such as antithrombin III, protein C, protein S, hyperhomocysteinemia, factor V Leiden mutation, and lupus anticoagulant,9 were not routinely performed in our department. Hemodynamic compromise was demonstrated echocardiographically in all patients; however, no right heart or pulmonary arterial thrombus was directly visualized. Right ventricular dilatation was observed in 12 patients, and corresponding free wall hypokinesis was documented in 5.

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Treatment Protocols In both groups, a 5000-unit intravenous bolus of heparin was administered immediately after the diagnosis was established, and a 1000-U/h heparin infusion was maintained during subsequent treatment. The cardiopulmonary status was monitored continuously, and vasoconstrictors (dopamine and/or dobutamine) were given intravenously, if necessary, to support cardiac function and maintain adequate tissue perfusion as long as hemodynamic instability persisted. When the procedure was finished, the patients were transported in the Intensive Care Unit (ICU), where they were monitored for 24 to 48 hours. Heparin infusion (500 U/h) was continued until effective warfarin loading was achieved. Warfarin was discontinued after 6 months in all patients. No inferior vena cava filters were implanted in any patient. In the LIT group, intrapulmonary catheterdirected thrombolysis was initiated after the diagnostic pigtail catheter was carefully exchanged for a 5-F hydrophilic catheter (multipurpose sidehole or tapered, angled) over a 0.035-inch stiff hydrophilic guidewire, which pierced the emboli and was anchored distally in the subsegmental branches for increased support. If the thrombus was organized and resistant to penetration, the catheter was maneuvered as close to the emboli as possible. Urokinase (4400 IU/kg over 10 minutes) was delivered directly into the thrombus or the artery followed by an infusion of 2000 IU/kg/h. The patient remained in the angiography suite, where progression of thrombolysis, catheter position, and improvement of central patency and peripheral pulmonary perfusion were checked every hour by lobar or segmental angiography with small infusions of contrast medium (5–10 mL) to avoid fluid overload. Thrombolytic therapy was terminated when vital signs had substantially improved regardless of the extent of angiographic improvement. In the ART group, the 6-F, dual-lumen Xpeedior rheolytic thrombectomy catheter was introduced over a 0.035-inch stiff hydrophilic guidewire and advanced to the segmental level of the pulmonary branches and buried deep into the clot if possible. Prior to activa-

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tion of the Xpeedior catheter, contrast infusion verified that the vessel diameter was . 6 mm (18-F) to allow sufficient space for safe operation of the catheter.19 A guiding catheter was not needed because contrast injections through the catheter lumen achieved adequate visualization for guidance. The catheter was manipulated back and forth inside the thrombus while activated, and with the aid of an interchangeable 5-F hydrophilic catheter (tapered, angled, or multipurpose), the guidewire was navigated into the upper, middle, and lower branches to access the target vessel, vary catheter curvature, tilt its tip against the vessel wall, and increase the effective thrombectomy radius. Xpeedior activation was alternated with local infusions of urokinase (100,000 IU) through the second effluent lumen. Periodic angiographic monitoring of thrombectomy progression was feasible by reverse contrast infusion through the same route. In stepwise fashion, the device was placed in each obstructed lobar and segmental branch until cardiovascular stability was restored. Operation of the AngioJet was avoided in the subsegmental branches owing to the increased risk of vessel wall damage and perforation.

Definitions Pre and postprocedural MS and relative MS improvement, defined as the post MS score minus the pre MS score divided by the pre MS score, were calculated for each patient. The shock index (SI), defined as the heart rate divided by the systolic blood pressure, was a useful quantitative indicator of hemodynamic status. An SI .1.00 is a relative indication for intervention, and an SI ,0.75 generally denotes restoration of cardiovascular stability. Clinical success was therefore defined as hemodynamic recovery, with stable cardiac rhythm and adequate peripheral perfusion (systolic pressure .130 mmHg, SI ,0.75). Because of the urgency of patient care and difficulties in follow-up, pulmonary artery pressures were not routinely measured pre and post therapy.

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Statistical Analysis Data on clinical success, angiographic results, total urokinase dose delivered, duration of intervention, and complications were collected from the hospital records. Statistical comparison of the relative MS improvement, total urokinase dosage, and duration of therapy between the treatment groups was performed with the unpaired t test using the SPSS statistical software package (SPSS, Chicago, IL, USA); the threshold of statistical significance was set at p50.05. Data are presented as the mean 6 standard deviation.

RESULTS In the LIT group, intrapulmonary thrombolysis was performed in 4 main pulmonary arteries (2 left, 2 right), 22 lobar arteries, and 36 segmental arteries. The UK dose was 2.0760.44 million IU (range 1.55–3.05) administered over a mean 11.4562.94 hours (range 8–18). Clinical success was achieved in all 8 patients without any fatalities; the MS fell from 17.3862.67 at baseline to 6.1361.46 (Table). Two minor groin hematomas occurred, but no major hemorrhage. Self-limiting gross hematuria was observed in all patients as the urokinase dose rose. All 8 patients were alive without recurrence at 1 and 12 months, although 1 patient died from cardiovascular causes after the 1-year follow-up. In the ART group, AngioJet thrombectomy was performed in 4 main pulmonary arteries (4 right), 23 lobar arteries, and 21 segmental arteries. Four of the patients received alternating low-dose (100,000-IU) urokinase infusions (0.7060.36 million IU, range 0.00–1.00), but 2 patients had major contraindications (recent abdominal surgery and recent stroke, respectively) and did not receive any urokinase. The duration of therapy in the ART group was 3.3761.41 hours (range 1.8–5.8). Total collected fluid was 483.36120.9 mL (range 350–650), and the activation time was 8.862.2 minutes (range 6.4–11.8), varying according to the thromboembolic burden and resistance. The MS in the ART group was reduced from 18.8362.86 to 6.8362.79 (Table), and the majority of thromboemboli in the main pulmo-

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TABLE Comparison of Local Intrapulmonary Thrombolysis (LIT) Versus AngioJet Rheolytic Thrombectomy (ART) in Massive Pulmonary Embolism

LIT (n58) ART (n56) p

Clinical Success

Pre-MS

Post-MS

100% (8/8) 83% (5/6)

17.3862.67 18.8362.86

6.1361.46 6.8362.79

Relative MS Improvement

UK Dose, Million IU

Duration of Therapy, h

0.6560.05 0.6360.17 0.76

2.0760.44 0.7060.36 ,0.0001

11.4562.94 3.3761.41 ,0.0001

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Continuous data presented as mean6standard deviation. MS: Miller score, UK: urokinase.

nary arteries and the lobar branches was successfully removed in 5 (83%) of 6 patients (Figure). Residual mural thromboemboli were seen in the segmental branches of 2 patients. The patient with recent stroke died during the procedure owing to thromboembolism from the upper wall of the right pulmonary artery, which collapsed while the right lobar branches were being debulked. The first patient experienced shortness of breath, prolonged inspiration, and brief episodes of bradycardia lasting an average of 10 seconds after activation of the Xpeedior catheter in a lobar branch. The bradycardia was attributed to short-term blockage of the atrioventricular node by red blood cell–derived adenosine, which induces third degree heart block. Intravenous aminophylline loading (250 to 500 mg over 30 minutes) successfully hindered blockage. However, during ami-

nophylline-protected thrombectomy in the second patient, brief tachycardia and erythema were observed, again after 10 seconds of central Xpeedior activation. The same patient reported concomitant aura symptoms and had a 3-second episode of apnea during subsequent thrombectomy efforts. The device was periodically activated for 5 to 7 seconds, with 1-minute intervals to allow washout of the local humoral byproducts. Nonetheless, brief self-limited tachycardia recurred, sometimes without clinical sequela. One of the 4 patients given adjunctive urokinase experienced self-limiting intraprocedural hemoptysis owing to accidental activation of the Xpeedior in a subsegmental branch. ART patients were not routinely screened for hemoglobinuria, but there was no case of acute renal failure during hospitalization despite the fact that the AngioJet’s recommended 10-minute op-

Figure l (A) Right selective angiogram depicts massive emboli in the right upper and middle lobe branches (black arrows), with diminished peripheral perfusion (initial Miller score of 17). (B) Selective activation of the Xpeedior catheter (black arrow) in the trunk of the right ascending branch. (C) Complete patency of the upper lobe branches was restored (final Miller score of 5).

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erational span was exceeded in 2 patients. All 5 patients with clinical success after the procedure were alive without any recurrence at 1 and 12 months after treatment.

Comparative Analysis Procedures using the ART technique were significantly shorter (p,0.0001) and employed significantly smaller amounts of urokinase (p,0.0001). The reduction in the Miller score was also statistically significant in both groups (both p,0.0001); however, there was no statistically significant difference in the relative MS improvement between the methods (p50.76, unpaired t test with Welch’s correction).

DISCUSSION The pathophysiological process of pulmonary embolism encompasses humoral vasoactive agents, such as serotonin from platelets, thrombin from plasma, and tissue histamine,20 which increase vascular resistance due to hypoxic vasoconstriction and induce alveolar hyperventilation, reflex bronchoconstriction, and pulmonary edema. Right ventricular dilatation and dysfunction with free wall hypokinesis evolve acutely.9,20 These are common echocardiographic findings of submassive and massive PE9 and represent the inability of the myocardium to overcome the acute rise of the right ventricular afterload. The corresponding clinical spectrum of submassive and massive PE ranges from normotensive right ventricular dysfunction to hypotension and shock or even cardiac arrest. The presence of shock elevates the mortality rate by three to seven fold.1,21 Pharmaceutical fibrinolysis is indicated for patients with shock, hypotension, or other evidence of systemic hypoperfusion attributed to MPE.7 However, the time necessary to achieve a clinical response with urokinase or alteplase varies from 2 to 12 hours, according to the texture and maturity of the thrombus.22 Moreover, controversy still exists over whether fibrinolysis infusion should be used in otherwise stable patients with right ventricular dysfunction.7 Although intravenous thrombolysis was reported more than a decade ago

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to be equally effective as direct infusion into the main pulmonary artery,23 we agree with several clinical investigators who support the local selective delivery of thrombolytics based on cumulative personal experience from peripheral vessels and dialysis access grafts.23 This view is strongly supported by more recent experimental data in animal models with PE.24 Catheter-directed intrapulmonary thrombolysis with urokinase has been investigated in 3 small clinical studies, which reported ;98% clot lysis and zero mortality with minimal complications.25,26 Although these results are superior to our ;65% MS reduction in the LIT group, we also had favorable clinical success and no mortality in our patients. Our rationale was to administer reasonable urokinase doses until hemodynamic balance was restored. It is important to remember that most patients with acute PE preserve a normal systolic pressure, but as right ventricular function is gradually worsened, hemodynamic collapse may ensue unexpectedly.20 Thus, progression of therapy depends more on SI reversal and less on angiographic scores. It is noteworthy that experimental flow studies have demonstrated rapid washout of transcatheter intra-arterial thrombolytic agents into the patent pulmonary arteries. However, after partial disruption of the embolus, the agents were diverted toward residual thromboemboli in the respective artery.27 This observation fosters the direct intrathrombus delivery of thrombolytics and highlights the synergistic effect of thrombofragmentation and adjunctive intrapulmonary lysis. According to morphometric analysis, the cross-sectional area of the pulmonary vascular bed increases toward the periphery and is almost doubled at the level of the 1-mm-diameter subsegmental arterioles.28 Fragmentation of large central thromboemboli by conventional interventional instruments (catheters and balloons)29,30 or mechanical or rheolytic thrombectomy devices11–16 creates smaller particles that propagate to the periphery, expanding the non-occluded cross-sectional area, with immediate benefits to the patient’s hemodynamic status. Achieving temporary cardiovascular relief extends the time available for therapy and theoretically in-

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creases survival odds. Furthermore, clot fragments offer a considerably larger area as a substrate for endogenous or pharmaceutical fibrinolysis.14 By utilizing powerful retrograde and radial saline jets, AngioJet’s Xpeedior catheter concomitantly splinters adjacent thrombus and aspirates fragments via the low-pressure exhaust lumen.31 Because hemolysis is a recognized side effect, the cumulative operational span of the AngioJet device is limited to 10 minutes. Pulverized thrombotic particles have a maximum size of 12 mm, which imparts no significant sequela even if embolized to the peripheral vessels.31 The manufacturer claims that under conditions of total occlusion, clot as far as 10 mm from the catheter tip is drawn in.31 In vitro studies have demonstrated that the effective radius of thrombectomy exceeds the catheter diameter,31,32 thus supporting the notion that AngioJet rheolysis is potentially superior to other mechanical concepts. In vitro, the AngioJet device has extracted thrombus in large diameter vessels and low-pressure fluid dynamic applications,33 such as interventional pulmonary thromboembolectomy. There is even a 4-F coronary catheter available, potentially appropriate for the subsegmental pulmonary vasculature. However, the AngioJet rheolytic capacity is often limited by the age of thrombus. In fact, clots tend to organize into vascularized connective tissue if they are older than 1 week,31,32 which may be the case if chronic DVT is responsible for MPE. ART for management of MPE, with or without adjunctive pharmaceutical thrombolysis, has been reported in 3 small series15,16,34 and one case report35 comprising 25 patients. Three deaths occurred in this patient group. Zeni et al.16 recently published a series of 17 patients treated with ART plus subsequent adjunctive high-dose reteplase infusion in 10. They reported 88% clinical success and 2 deaths, which is similar to our experience. The main procedural side effect of the AngioJet thrombectomy device is in situ hemolysis by the high-pressure saline jets, which decimate normal circulating red blood cells along with the clot, raising plasma-free hemoglobin.31 Rheolytic granulation of clot and whole blood components also liberates

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other humoral agents that are probably responsible for the intraprocedural side effects we encountered. Bradycardia and third degree heart block owing to liberation of adenosine from red blood cells have been reported during AngioJet procedures in the coronary arteries,36,37 as well as in the pulmonary16 and peripheral vasculature.38,39 The brief tachycardia, erythema, and aura symptoms we observed may be attributed to platelet-derived serotonin, which is also rapidly degraded. Like Zeni et al.,16 one of our patients experienced apnea. Although the responsible pathophysiological mechanism is unknown, it is feasible that rheolysis-mediated mechanical irritation of the afferent vagal pulmonary cfibers could stimulate the apneustic center. However, these hypotheses are based only on clinical observations and logical assumptions, without supporting experimental data. In any case, we recommend periodic activation of the device to avoid these phenomena. Care must be exercised during activation and manipulation of the AngioJet catheters because operation in the subsegmental pulmonary branches may induce vessel wall disruption and hemoptysis, as occurred in one of our cases. Hence, avoiding activation of the AngioJet or other mechanical thrombectomy devices at the subsegmental level cannot be overstressed. The 6-mm diameter threshold set by Biederer et al.19 or a vessel diameter/ catheter size ratio no less than 3 could serve as useful guidelines during percutaneous thrombectomy in the pulmonary arterial tree.

Limitations The major limitations of our study are its retrospective design and the small numbers of patients in each group. An additional technical limitation could be the fact that the AngioJet catheters were navigated in the pulmonary tree without a guiding catheter, which could theoretically have eased selective negotiation of segmental branches. Finally, vena cava filters were not implanted on the basis of published guidelines40 stating that filters should be utilized whenever PE or DVT coexist with contraindication, complication, or failure of anticoagulation. However, temporary or retrievable filters represent an option

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for high-risk patients with residual DVT to prevent recurrent PE and should be considered when managing such critical patients.

Conclusions Percutaneous thrombectomy techniques are emerging therapeutic methods for treating massive PE. According to our limited experience, AngioJet rheolytic thrombectomy plus adjunctive low-dose urokinase seems to restore hemodynamic balance more rapidly and with a lower dose of thrombolytic agent than intrapulmonary high-dose thrombolysis. Pharmacological protection of the atrioventricular node and intermittent activation of the AngioJet device can easily limit intraprocedural side effects. Prospective trials with larger series of patients are required with a view to enhance statistical significance and corroborate our clinical results.

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