Medicine of the Future in America

Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism: Initial Thrombolysis

Most patients (73%) initially received streptokinase therapy in accordance with the policy of our institution. However, the distribution of both thrombolytic agents was similar between the two treatment groups. Here
Twenty-three patients underwent control spiral CT scanning, and 10 patients underwent control pulmonary angiogram between 24 and 36 h. Seven patients who were in very unstable condition did not undergo repeat spiral CT scan or pulmonary angiogram (three patients underwent rescue surgical em-bolectomy; four patients underwent repeat thrombolysis). Three patients who had undergone rescue surgical embolectomy underwent additional pulmonary angiography before surgery according to the surgeon’s requirement. Persistent proximal thrombi were reported in all 33 patients who had undergone control spiral CT scan or pulmonary angiogram. Thrombi were bilateral in 24 patients (73%) and unilateral in 9 patients (27%). There was no significant difference between the two groups in terms of thrombi location.
The mean duration of hospital stay was 12 ± 5 days. Of the 26 patients who underwent repeat thrombolysis, 19 (73%) were initially treated with streptokinase and subsequently received tissue plasminogen activator (t-PA), while 7 (27%) who had initially been treated with t-PA were given streptokinase. All patients in the surgically treated group received a vena caval filter perioperatively, compared with only 8 of 26 patients in the repeat-thrombolysis group (percutaneous femoral or jugular approach) [100% vs 31%, respectively; p < 0.0001].
The in-hospital clinical course was uneventful in 11 patients (79%) who had undergone rescue embolectomy, compared with 8 patients (31%) who had undergone repeat thrombolysis (p = 0.004). This unfavorable evolution in the condition of patients in the repeat-thrombolysis group was the result of a higher mortality rate, which was associated with more recurrent PE. A total of 10 patients (38%) died in the repeat-thrombolysis group, of whom 3 died from recurrent PE, 3 died from refractory cardiogenic shock, and 4 died from major bleeds.

This entry was posted in Pulmonary function and tagged embolism, surgery, thrombolysis.
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