Hi ASOK pl read up this also but patient should be in tertiary care
hospital for all these
Recent advances(IN TMT OF PE)
I. Pulmonary embolectomy:
Indications:
 Acute massive PE with failure of thrombolytic therapy.
Or contra indication to thrombolytic therapy:
 In very serious patients who may not survive 1-2hrs required to derive
benefit from thrombolytic therapy.
Mortality: in embolectomy -50%
Pre requisite: pulmonary angiography to show the site
& extent of pulmonary obstruction.
Importantly diagnosis must be ensured- patients with alternative diagnosis like
MI if mistakenly subjected to embolectomy have high mortality .
II.. Catheter fragmentation of embolus: (not widely used)
-In Acute massive pulmonary embolism:
Embolism is sometimes partially disrupted with a catheter inserted in
pulmonary artery
-thereby improving pulmonary flow, the smaller fragments then respond more
rapidly to thrombolytic therapy.
. Procedures on Inferior vena cavae.
Indications:
1. Only in acute DVT situations having absolute contrandications for
anticoagulation (active bleeding,thrombocytopenia,urgent surgery)
2Recurrent PE in spite of adequate anticoagulation –residual thrombus is
present in deep veins in 90% of cases.
¶3. PE in which anticoagulation is contraindicated.(immediately after neuro
surgery)
.4..;Relative indications (Decision has to be individualized )
Primary /metastatic CNS cancers
Free floating proximal iliac vein thrombi
Patients with limited cardiopulmonary reserve.
Devices: Percutaneously inserted filters /umbrellas into IVC below the origin
of renal vessels. Refer below.
Benefits: disputed; even without them, recurrence of PE is low (5%only)
Chronic thrombo embolic pulmonary hypertension is also rare.
So indicated only in the above rare conditions.
Removal of the filter:
To be removed within 2-4wks;
long term implants cause thrombosis /device migration.
Filters:
Small filtration devices can be placed within the lumen of the Vena cava to
prevent migration of the pulmonary emboli.
Such Devices available; 1. Greenfield filter; 2. Nitinol Filter
3. Trapease 4. Bird nest filter 5. Vena Tech Filter
The procedure to implant is simple and easy and is performed under local
anesthesia.
.. Mechanical Thrombectomy
¶This is the latest mode in the treatment of DVT.
The clot can be removed with the use of “Trellis Catheter”.
A small catheter with inflatable balloon on either ends is introduced inside the
clotted vein.
The balloons are inflated and clots are dissolved using thrombolytic.
The catheter is activated to spin and macerate the clot which is sucked and
removed through a side port.
The procedure is often performed in conjunction with a filter.