Pulmonary Artery Intervention for Submassive Pulmonary Embolism From an Arm Superficial Venous Access

Abstract

Background. Pulmonary embolism (PE) endovascular interventions are often approached from an internal jugular or femoral venous access. There are multiple advantages of right basilic vein (RBV) access for both patient and operator, especially in the setting of morbid obesity. We hereby describe the case of a 48-year-old, morbidly obese man who presented with acute respiratory insufficiency and was found to have bilateral submassive subocclusive PE, worse on the right. The right ventricular to left ventricular ratio was 2.1 and troponin was elevated. A 7 Fr sheath was placed in the RBV under ultrasound guidance. Selective bilateral pulmonary arteriography was then performed. A 106 x 12 cm EKOS catheter was placed in the segment of highest thrombotic burden for a 6-hour protocol of catheter-directed ultrasound-facilitated thrombolytic therapy. The patient recovered well on a direct oral anticoagulant and his acute symptoms resolved. Treating massive/submassive PE from a RBV access offers the convenience and safety of superficial venous access (for patient and operator), better patient comfort, less venous stasis during therapy with ability to ambulate, less potential for bleeding and vascular complications, less potential for operator radiation exposure when compared with the jugular approach, and better operator ergonomics.

J INVASIVE CARDIOL 2021;33(2):E92-E94. Epub 2021 Jan 7. doi:10.25270/jic/20.00348

Key words: basilic vein access, catheter-directed ultrasound-facilitated pulmonary artery thrombolytic therapy, EKOS catheter, submassive pulmonary embolism, superficial venous access, thrombolytic therapy, upper extremity

Pulmonary embolism (PE) endovascular interventions are often approached from an internal jugular or femoral access. There are multiple advantages of right basilic vein (RBV) access for both patient and operator, especially in the setting of morbid obesity. We hereby describe the case of a submassive PE that was treated with catheter-directed ultrasound-facilitated thrombolytic therapy from a right arm superficial venous access.

Case Presentation

A 48-year-old morbidly obese gentleman presented with severe dyspnea at rest. He was tachypneic and hypoxic, and quickly progressed to moderate respiratory distress requiring bilevel therapy. Contrast computed tomography of the chest revealed bilateral subocclusive PE, worse on the right. Troponin was elevated and the right ventricular to left ventricular ratio was 2.1. The thrombotic burden extended from the right main pulmonary artery (PA) to the middle and lower lobe branches; however, on the left, it was disseminated peripherally, suboccluding most of the lobar and segmental branches of the left PA without a central component. For that reason, we thought the patient would benefit from right PA catheter-directed thrombolytic therapy, but the non-central nature of the thrombotic distribution in the left PA branches did not favor a left-sided catheter-directed therapy.

Technique

The technical highlights are illustrated in Figure 1. First, a 7 Fr sheath was placed in the RBV under ultrasound guidance. Therapeutic activated clotting time was achieved. Then, a 5 Fr Headhunter catheter (Merit Medical) was advanced over a Super-Stiff Amplatz wire (Boston Scientific) up to the level of the left PA and selective angiography was performed. A 5 Fr internal mammary catheter was then directed over an 0.018˝ Glidewire Advantage (Terumo) followed by a 0.035˝ stiff-angled Glidewire to perform a selective right middle lobe pulmonary angiography. This location was selected for lytic therapy based on the relative amount of subocclusive thrombus within the right PA. The wire was looped into a right middle lobe segmental branch and exchanged for a 106 x 12 cm EKOS catheter for a 6-hour protocol of catheter-directed ultrasound-facilitated thrombolytic therapy. The patient had no activity restrictions except significant flexion/extension of the right arm and walked in his room during the infusion. The patient recovered well on a direct oral anticoagulant and his acute symptoms resolved.

Discussion

Treating massive/submassive PE from a RBV access offers the following advantages:

• convenience and safety of superficial venous access (for patient and operator);
• better patient comfort;
• less venous stasis during therapy with ability to ambulate;
• less potential for bleeding and vascular complications;
• less potential for operator radiation exposure when compared with the jugular approach; and,
• better operator ergonomics.

In cases where bilateral PA catheter-directed therapy is needed, an upper-extremity venous access approach is not ruled out, albeit with the low morbidity of an additional ultrasound-guided venous access site in the same field, ie, either of the 2 brachial veins or the cephalic vein (in the most usual vascular anatomy). The advantage of brachial vein access over cephalic vein access is that it is easier to technically get to the right heart; however, cephalic vein access does not usually entail the risk of inadvertent brachial artery puncture. This bilateral PA treatment approach maintains all the advantages outlined above while preserving the simplicity of the set-up and the convenience of postprocedural nursing care.

Conclusion

Right arm superficial venous access seems safe, effective, and convenient, and also prevents the dreaded venous stasis during therapy of submassive or massive PE while potentially reducing radiation exposure to the operator.

From Ascension Saint Thomas Heart, Murfreesboro and Nashville, Tennessee.

Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Lichaa reports no conflicts of interest regarding the content herein.

Manuscript accepted April 21, 2020.

The author reports that patient consent was provided for publication of the images used herein.

Address for correspondence: Hady Lichaa, MD, FACC, FSCAI, FSVM, RPVI, Ascension Saint Thomas Heart, 1840 Medical Center Pkwy #201, Murfreesboro, TN 37129. Email: hady.lichaa@gmail.com or hady.lichaa@ascension.org