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Click 40 year old male patient with high clinical suspicion of acute PE. Left lower extremity DVT, hypoxia, chest pain

Technique: A CT of the chest after the intravenous administration of 140 cc Omnipaque 300 with thin contiguous axial images were obtained from the thoracic inlet to the level of the adrenal glands (GE scanner, mA: 490, kVP: 120, slice thickness: 1.25mm, 140 cc Omnipaque 300)

Findings: Massive saddle pulmonary emboli, including nearly occlusive thrombus in right main pulmonary artery, with extension into right upper, middle, and lower lobar, segmental, and subsegmental branches. Distal left main pulmonary artery emboli also extend into left upper and lower lobar, segmental and subsegmental branches.

The main pulmonary artery is mildly dilated and there is dilatation of the right atrium and right ventricle suggestive of right heart strain. There is no pericardial effusion.

There is bibasilar atelectasis. Vague nonenhancing peripherally located wedge-shaped bilateral lower lobe consolidations are suspicious for early pulmonary infarcts. The trachea and central airways appear patent. There is no pleural effusion. No thoracic lymphadenopathy is identified. The visualized portion of the upper abdomen and pelvis is unremarkable. No suspicious osseous lesion is identified.

Impression:

1. Massive bilateral central, lobar, segmental and subsegmental pulmonary emboli.
2. Dilatation of the main pulmonary artery, right atrium and right ventricle suggestive of right heart strain.
3. Nonenhancing wedge-shaped bilateral lower lobe consolidations suspicious for early pulmonary infarct.


Click 40 year old male patient with acute massive pulmonary embolism (PE).
TECHNIQUE:
After the risks, benefits, and alternatives were explained, informed written consent was obtained from the mother Sara Bradley.
The patient was identified and placed in the supine position. The right neck and bilateral groins were prepped and draped with maximum sterile barrier technique.
Ultrasound evaluation of the right internal jugular vein showed it to be patent and compressible. A copy of the image was placed in the medical record.
2% lidocaine local anesthesia was administered. Under ultrasound guidance, the right internal jugular vein was accessed using a micropuncture needle. A guidewire was passed and the needle was exchanged for the micropuncture sheath. The sheath was exchanged for an Bentson wire over which a 9 Fr Sheath was inserted with its tip in the main pulmonary artery. A 5 French pigtail catheter was inserted over a 0.035 Bentson wire and its tip selecting the main pulmonary artery.
Main pulmonary angiogram was then performed. From this position, the sheath was advanced over Amplatz wire 0.035 Inch with its tip in the right pulmonary and an angiogram with 10 ml/sec of 20 ml Omnipaque contrast was performed from this position. These injection rates and volumes were used during all remaining angiograms. Pressures in the main pulmonary artery and right atrium were measured before and after the alteplase thrombolysis/ mechanical thrombectomy.
Right pulmonary catheter directed thrombolysis using 6 mg of alteplase diluted in 10 ml sterile water and injected over 2 minutes. Then, right pulmonary mechanical thrombolysis using rotational pigtail (5 French) catheter was then performed under fluoroscopic guidance and cardiopulmonary monitoring.
Right pulmonary mechanical thrombolysis using aspiration (7 French) catheter was then performed under fluoroscopic guidance and cardiopulmonary monitoring. A completion right pulmonary angiogram was performed.
An additional 6 mg of alteplase diluted in 10 ml sterile water and injected over 2 minutes into the right main pulmonary artery.
Then, a right upper lobe pulmonary mechanical thrombolysis using the Cleaner Argon device was then performed under fluoroscopic guidance and cardiopulmonary monitoring. This was followed by lower lobe pulmonary mechanical thrombolysis using the Cleaner Argon device. Completion right pulmonary angiogram followed by main pulmonary angiogram, were then performed successfully.
At the conclusion of the study, catheters, wires and sheath were removed successfully. Patient tolerated the procedure and was transferred back to the neurosurgery critical care unit under primary team escort.

FINDINGS:
The main and right pulmonary angiograms, before the alteplase thrombolysis/ mechanical thrombectomy, showed large filling defect in the main right pulmonary artery. There was poor and extremely decreased right pulmonary perfusion when compared to the left side. There was dilatation of the main and right pulmonary arteries.
Pressure in the main pulmonary artery, before the alteplase thrombolysis/ mechanical thrombectomy, was 39/19 with mean of 24 mm Hg.
The main and right pulmonary angiograms, after the alteplase thrombolysis/ mechanical thrombectomy, showed significant decrease in the filling defect in the main right pulmonary artery. There was significant improvement in right lung perfusion. Respiratory and heart rates were improved as detailed in the vital signs procedural sheet.
Pressure in the main pulmonary artery, after the alteplase thrombolysis/ mechanical thrombectomy, was 28/12 with mean of 19 mm Hg.
Pressure in the right atrium, after the alteplase thrombolysis/ mechanical thrombectomy, was 13/5 with mean of 8 mm Hg.