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Vol. 47. Issue 1.
Pages 17-24 (January 2011)
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Vol. 47. Issue 1.
Pages 17-24 (January 2011)
Original Article
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Endovascular Treatment of a Haemodynamically Unstable Massive Pulmonary Embolism using Fibrinolysis and Fragmentation. Experience with 111 Patients in a Single Centre. Why don’t we follow ACCP Recommendations?
Tratamiento endovascular mediante fibrinólisis y fragmentación del embolismo pulmonar masivo con inestabilidad hemodinámica. Experiencia de un solo centro en 111 pacientes. ¿Por qué no seguimos las recomendaciones de la ACCP?
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Miguel Ángel de Gregorioa,
Corresponding author
mgregori@unizar.es

Corresponding author.
, Alicia Labordaa, Ignacio de Blasb, Joaquín Medranoa, Antonio Mainara, Mikel Oribec
a Grupo de Investigación Técnicas de Mínima Invasión (GITMI), Universidad de Zaragoza, Añadir Unidad de Cirugía Mínimamente Invasiva Guiada por Imagen, Hospital Cínico Universitario Lozano Blesa, Zaragoza, Spain
b Departamento de Enfermedad Animal y Epidemiología, Universidad de Zaragoza, Zaragoza, Spain
c Servicio de Respiratorio, Hospital de Galdakao, Galdakao, Vizcaya, Spain
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Abstract
Introduction

Fibrinolysis is recommended in several consensus documents for the treatment of hemodynamically-unstable massive pulmonary embolism (MPE).

Material and methods

A total of 111 patients were treated in a single center from January 2001 to December 2009. Fifty-five were male and 56 female, all diagnosed with hemodynamically-unstable MPE (systolic arterial pressure > 90 mmHg) with at least two of the following criteria: Miller index > 0, ventricular dysfunction, and need for vasoactive drugs. Local fibrinolysis with urokinase was performed in all cases as was fragmentation with a pig-tail catheter in most. An inferior vena cava (IVC) filter was implanted in 94 patients as a prophylactic measure.

Results

Technical success was 100%. The Miller index improved from 0.7 ± 0.12, pre-treatment, to 0.09 ± 0.16. Mean pulmonary arterial pressure went from 39.93 ± 7.0 mmHg to 20.47 ± 3.3 mmHg at the 30-90 day follow-up. Ninety-four patients had IVC filters implanted, 79% of which were withdrawn satisfactorily. Seven patients died: 3 due to neoplasia; 3 due to right cardiac failure at 1, 7 and 30 days; and another died of a brain hemorrhage within the first 24 hours. There were complications in 12.6% of the cases, of which 4.5% were major.

Conclusion

Local fibrinolysis with fragmentation achieves rapid normalization of the pulmonary pressure and is a safe and effective method for the treatment of hemodynamically-unstable MPE.

Keywords:
Fragmentation
Fibrinolysis
Massive pulmonary embolism
Resumen
Introducción

La fibrinolisis está recomendada en los diferentes consensos para el tratamiento del embolismo pulmonar masivo hemodinámicamente inestable (EPmHI).

Material y métodos

En un solo centro desde enero de 2001 hasta diciembre de 2009 se han tratado 111 pacientes (55 hombres y 56 mujeres) diagnosticados de EPmHI (presión arterial sistólica < 90 mmHg) con al menos dos de los siguientes criterios: índice de Miller > 0, disfunción ventricular y necesidad de drogas vasoactivas. En todos los casos se realizó fibrinolisis local con uroquinasa y en la mayoría fragmentación con catéter pig-tail. Se implantó un filtro de vena cava inferior (VCI) en 94 pacientes como medida profiláctica.

Resultados

El éxito técnico fue del 100%. El índice de Miller mejoró de 0,7 ± 0,12 pre-tratamiento a 0,09 ± 0,16. La presión arterial pulmonar media pasó de 39,93 ± 7,0 mmHg a 20,47 ± 3,3 mmHg en el control de 30-90 días. A 94 pacientes se les implantó un filtro de VCI que se pudo retirar en el 79% de forma satisfactoria. Siete pacientes fallecieron: 3 en el curso de su neoplasia, 3 por insuficiencia cardíaca derecha a 1, 7 y 30 días y otro falleció de hemorragia cerebral en las primeras 24 horas. Hubo complicaciones en el 12,6% de los casos, de las que 4,5% fue mayor.

Conclusión

La fibrinolisis local con fragmentación consigue la normalización rápida de la presión pulmonar y constituye un método seguro y eficaz para el tratamiento del EPmHI.

Palabras clave:
Fragmentación
Fibrinolisis
Embolismo pulmonar masivo
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Copyright © 2011. Sociedad Española de Neumología y Cirugía Torácica
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