ARTERIAL OCCLUSIVE

PULMONARY EMBOLISM

Pulmonary Embolism
 

Anatomy

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Pulmonary Embolism
Indicators of early PE-related death and haemodynamic deterioration in patients with non-high-risk PE
Pulmonary Embolism
National Early Warning Score
 

Indications

Risk Determination

Low: Normal heart function, mortality < 1%
Intermediate: RV dysfunction and/or biomarker indication of myocardial damage
High: Cardiogenic shock

RV/LV ratio on CT**: > 0.9 is abnormal (30-day mortality predictor in PE)

The **PERC rule** can be applied to patients where the diagnosis of PE is being considered, but the patient is deemed low-risk. A patient deemed low-risk by the physician’s clinical judgment, who is also under 50 years of age, with a pulse <100 bpm, SaO2 ≥95%, no hemoptysis, no estrogen use, no history of surgery/trauma within 4 weeks, no prior PE/DVT, and no current signs of DVT, can safely be ruled out and does not require further workup.

PESI score

PEITHO trial

High risk

  • Arterial hypotension (<90 mmHg systolic);
  • Circulatory collapse with need for cardiopulmonary resuscitation (shock index: heart rate/systolic blood pressure >1
  • Right ventricular afterload stress and/or pulmonary hypertension (mean pulmonary arterial pressure >25 mmHg)

Intermediate risk

  • Haemodynamic deterioration despite anticoagulation (treatment failure) and
  • Contraindications for systemic thrombolysis or
  • Failure of systemic thrombolysis
 

Contra indications

Absolute

  • History of haemorrhagic stroke or stroke of unknown origin
  • Ischaemic stroke in previous 6 months
  • Central nervous system neoplasm
  • Major trauma, surgery, or head injury in previous 3 weeks
  • Bleeding diathesis
  • Active bleeding

Relative

  • Transient ischaemic attack in previous 6 months
  • Oral anticoagulation
  • Pregnancy or first postpartum week
  • Non-compressible puncture sites
  • Traumatic resuscitation
  • Use of ECMO
  • Advanced liver disease
  • Infective endocarditis
  • Active peptic ulcer
  • Refractory hypertension (systolic BP >180 mmHg)
  • Infective endocarditis
  • Active peptic ulcer
  • Refractory hypertension (systolic BP >180 mmHg)

 

Workup

 

Pre procedural

 

Materials

Essentials

  • Ultrasound
  • Sterile drapes
  • 8F sheath
  • Lidocaine 1%
  • Heparine
  • Pigtail catheter
  • Rosen wire
  • Inari kit

Non-Essentials

 

Positioning the patient

  • Supine
  • Head first

 

The procedure in steps

  • Time-out
  • Continuous monitoring of systemic blood pressure, heart rate and electrocardiography.
  • US guided access femoral vein
  • At this time decide whether to use Proglides
  • 8F sheath
  • 100 U Heparine per kg
  • Pigtail with Rosen wire to pulmonary trunk
  • Invasive pulmonary artery (PA) pressure measurement and mixed venous oxygen saturation before removing the catheters to assess the effect of treatment.
  • Angiography - 10 ml of contrast at 5 ml/s preferably in the 20° left anterior oblique (LAO) view
  • Catheterization of the right pulmonary artery
  • Deep placement of the wire, followed by the catheter
  • Wire exchange to Amplatz with short floppy tip
  • Sheath exchange to 24F
  • Advance to right pulmonary artery
  • If not possible to trunk and insert 16F sheath
  • Advance that into the artery
  • Advance the 24F over the 16F
  • Remove the 16F
  • Thrombosuction
  • Connect the syringe
  • Pull it vacuum
  • Open the system to the syringe
  • If necessary retract the 24F under suction
  • Empty the syringe in the filter
  • Return the filtered blood to the patient through the 24F

  • If there is no thrombus aspirated, consider the Retriever
  • Repeat the invasive pulmonary artery (PA) pressure measurement and mixed venous oxygen saturation before removing the catheters to assess the effect of treatment.

  • Repeat the steps for the left side

  • Close with figure of 8 suture through the subcutis
  • Sign-out

 

Tips and tricks

 

Aftercare

 

Complications

Major 2.4%

  • Groin hematomas (n=11: requiring transfusion)
  • Non-cerebral hemorrhages (n=5: sites unspecified, requiring transfusion)
  • Massive hemoptysis requiring transfusion (n=2)
  • Renal failure requiring hemodialysis (n=1)
  • Cardiac tamponade (n=1)
  • Death (n=5) occurred in 25 patients: five procedure-related deaths were all associated with the Angio Jet device

 

Post-op

 

Follow-up

 

Report

 

Literature

File NameTypePermissionsChanged DateDateSize

  1. J. Mark Ryan, MD, S. M. Key, Siobhan A. Dumbleton, MD, and Tony P. Smith, MD Nonlocalized Lower Gastrointestinal Bleeding: Provocative Bleeding Studies with Intraarterial tPA, Heparin, and Tolazoline J Vasc Interv Radiol 2001 Nov;12(11):1273-7

  2. Baum ST. Arteriographic diagnosis and treatment of gastrointestinal bleeding. In Baum ST, Pentecost MJ, eds. Abrams' angiography interventional radiology. 2nd ed. Philadelphia, Pa:Lippincott, Williams & Wilkins, 2006:488.

  4. Poultsides GA, Kim CJ, Orlando R 3rd, et al. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008;143:457-461.

  5. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006;17:959-964.

  6. Dixon S, Chan V, Shrivastava V et al. Is there a role for empiric gastroduodenal artery embolization in the management of patients with active upper GI hemorrhage? Cardiovasc Intervent Radiol. 2013 Aug;36(4):970-7.

  7. Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012;13 Suppl 1:S31-S39.

  9. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22(2):209-24.

  10. Sildiroglu O, Muasher J, Arslan B, Sabri SS, Saad WE, Angle JF, Matsumoto AH, Turba UC. Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy. J Clin Gastroenterol. 2014;48(8):687-92.

  11. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  13. van Dam J, Brugge WR. Endoscopy of the upper gastrointestinal tract. N Engl J Med. 1999;341(23):1738-48.

  15. Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am. 2002 Nov;86(6):1357-99.

  16. Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-22

  18. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  19. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998 Aug;64(8):723-8.

  20. Cummings CL. Value of early capsular endoscopy for severe gastrointestinal bleeding. J Natl Med Assoc. 2004;96(12):1653-6.

  21. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med. 2001;344(3):232-3.

  24. Lim JK, Ahmed A. Endoscopic approach to the treatment of gastrointestinal bleeding. Tech Vasc Interv Radiol. 2004 Sep;7(3):123-9.

  25. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998; 43:79–84.

  26. Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med. 2003 Oct;33(4):297-311.

  27. Imbembo AL, Diverticular disease of the colon. In: Sabiston D, Editor. Textbook of Surgery (14th edn). Philadelphia, PA:WB Saunders, 1992:910.

  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

  33. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13(1):114-7

  34. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  35. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  36. Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12:195-200.

  37. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  38. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, Rat P, Ricolfi F, Krausé D. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008 Apr;42(4):361-7.

  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

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