Treatment Procedure
Patients were taken to the hybrid operating room for EKOS APT after stabilization of hemodynamic status with the support of VA-ECMO. For the placement of the EkoSonic Endovascular System common femoral vein access was established by placement of a bilateral 6 French vascular sheath. Digital subtraction angiography was performed in two bilateral anterior oblique projections with the pigtail diagnostic catheter positioned in the main pulmonary artery. Once the location of a pulmonary arterial thrombus was identified angiographically, the angiographic catheters were exchanged for an EkoSonic infusion device, which was navigated over a 0.035-inch angled guidewire, such that the distal tip of the EKOS infusion catheter was positioned at the distal edge of the thrombus under fluoroscopy (Figure 2).
Patients were transferred to the ICU for thrombolytic infusion with tPA administered at a rate of 1 to 1.5 mg/hr (0.5 to 0.75 mg/hr through each catheter, in case of bilateral PE). 1 mg bolus tPA per catheter was administered to the patients before the overnight infusion. Normal saline coolant was infused at a rate of 40 cc/hr, through the coolant port of the EKOS infusion catheter.