(1383) Targeted Thrombolytic Therapy Delivered via Pulmonary Artery Catheter for Massive Pulmonary Embolism

Introduction: Thrombolysis for massive PE has become standard of care due to reduced mortality compared to anticoagulation alone. Catheter directed thrombolysis is thought to be associated with a lower bleeding risk compared to systemic thrombolysis however not recommended for massive PE and has controversial evidence for submassive PE. This case highlights the use of a pulmonary artery catheter (PAC) to provide CDT in the case of a patient with CI to systemic thrombolysis.

Description: The patient is a 64-yo male admitted for acute massive PE with a PMH of PAD with chronic occlusion of the abdominal aorta and bilateral common iliac arteries sp bilateral axillary femoral bypass with an occluded left-sided graft. Pertinent is a recent hospitalization due to a massive gastric variceal bleed.
HD0:
Pulmonary Embolism Response Team recommended anticoagulation only due to stability. Unfortunately, patient required intubation for decline in mental and respiratory status with subsequent need for vasopressors. Patient had CI for systemic tpa and was not a candidate for ECMO or CDT due to vascular disease.
HD1:
Progressive decline requiring 3 vasopressors to maintain MAP>65mmHg. ECHO showed severe reduction of RV function and RV dilation. Patient was moribund; thus, multidisciplinary decision was made to initiate tPA at a rate of 1 mg/hr for 8 hr via PAC.
HD2:
Following 8 hr infusion, PA pressures remained elevated but vasopressor requirements decreased significantly; due to this favorable response, the infusion was repeated. Additional hemodynamic improvements and a reduction in PA pressures were observed after completion of second infusion and patient was transitioned back to heparin drip. See graphics.
The patient left the ICU after 14 days and discharged on day 25. Alive at 2-mo follow up.

Discussion: PACs are performed by many intensivists in the ICU. Utilization of a PAC allows for continuous hemodynamic monitoring and provides accurate measurements that can be used to evaluate therapy, including information about RV and LV performance.
In patients at high risk for short-term mortality, PA-CDT may be an alternative to the standard CDT when systemic thrombolysis poses significant safety concerns. Significant clinical improvements were seen in this patient without complete resolution of thrombi.