PE THROMBOLYSIS: PROCEDURE HIGHLIGHTS

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Normal MAIN PA pressures

Systolic: 15 – 25 mmHg

Diastolic: 8 – 15 mmHg

Injection flow rates:  (Absolute contraindication for PA angiography >100mmHg systolic; Relative = 80/20 mmHg)

  • Main pulmonary artery, 20 mL/s for 40 cc
  • Left pulmonary artery or right pulmonary artery, 15 mL/s for 20 cc at 30 fps
  • Lobar or segmental, 5 mL/s for 10 cc at 30fps

PROTOCOL (PROVIDERS APPROACH VARIES):

  • Sheath to measure pressures at bedside: 8F X 80cm sheath
    • -or-  7-8F x 11 cm sheaths
  • Main PA Selection Catheter: 6F x 110 cm angled pigtail catheter or 5F pigtail catheter (eg 155 cm)
    • Exchange length glide wire for selection
  • R/L PA Selection Catheter: 5F MPA/DAV/VERT (e.g. 125 cm Vert cath)
  • Bilateral Femoral access (Jugular vein preferred by some)
  • Measure Right Atrial and Main PA pressures
  • Infusion Catheter placement: Over Exchange length Amplatz wire (260 cm)
    • EKOS: 12 cm x 106 cm (eg)
    • EKOS: Attach heparin to sheath, tpa to drug, and NS to coolant
  • Sheath Heparin: 500U/hr in 1 sheath and 250U/hr per sheath if 2 sheaths
  • Infusion of tPA: 1mg per hour per catheter (24 hour duration)
    • Some reduce to 0.5 mg per hour per catheter s/p 6 hours
    • Some inject 3 mg tPA per PA artery primary to starting infusion
    • ***Maximum of 20 mg per 24 hours for up to 96 hours
  • If fibrinogen <150 , change tPA to NS at 30 cc/hr & restart systemic heparin
    • Cryoprecipitate to replete fibrinogen

 References:

Thoracic Key – Pulmonary Angiography