PROCEDURE:Â
- Inferior venacavogram and IVC filter placement Â
- Bilateral pulmonary artery infusion catheter placement
INDICATION: Submassive pulmonary embolism
DATE:
OPERATORS:
MEDICATIONS: Zofran 4 mg IV, Benadryl 50 mg IV
CONTRAST: 20 ml of Omnipaque 350
FLUOROSCOPY TIME: 9.7 minutes
FILTER TYPE: Cook Celect
ACCESS SITE: Right internal jugular vein with ultrasound
COMPLICATIONS: None
TECHNIQUE:
The risks, benefits, and alternatives to the procedure were explained to the patient. The specific risks of bleeding, infection, pulmonary embolism, filter mal deployment, and filter migration were detailed and accepted. Written informed consent was obtained.Â
The patient was assessed for conscious sedation but was not an adequate candidate because he was not NPO. The procedure was performed with local anesthesia. A dedicated nurse monitored heart rate, blood pressure, and oxygen saturation throughout the procedure. A time out was performed prior to procedure initiation.
The right neck was prepped and draped in sterile fashion.Â
The vascular structures were ultrasonographically evaluated.  Images were stored and transferred to PACS. Under ultrasound guidance, the right internal jugular vein was accessed with a micropuncture needle. Vein patency and needle entry were documented. A 0.018″ wire was placed and the needle exchanged for a 5 French dilator.
An Amplatz wire was advanced into the inferior vena cava, and the dilator exchanged for a 5 French marker pigtail catheter. Inferior venacavography was performed using nonionic contrast. This is a baseline study to define variant anatomy, caval size, location and number of renal veins, and to evaluate for ileocaval thrombus.
The Amplatz wire was replaced, and the pigtail exchanged for the Cook Celect filter delivery system.
Under direct fluoroscopic guidance, the filter was positioned and deployed. A hand injection was performed to assess filter position.
The sheath was exchanged over a guidewire for a 6 French vascular sheath. A 5 French pigtail catheter and Bentson guidewire were used to select the main pulmonary artery. Attempts were made to transduce the pulmonary artery pressure.Â
The pigtail was advanced into the left lower lobe pulmonary artery. The pigtail catheter and sheath were exchanged over a Rosen guidewire for a 6 French Balkin sheath and a 5 French 90 cm x 20 cm Unifuse thrombolysis catheter. The Rosen guidewire was removed and the occlusion wire for the thrombolysis catheter was placed.
The right internal jugular vein was again punctured using identical technique described above. An image documenting needle entry was saved and stored to PACS. Using the same technique, a second UniFuse catheter was placed at the right lower lobe pulmonary artery.
Both sheaths were sutured to the skin with 2-0 Ethilon. The infusion catheters were secured to the sheaths with 3-0 Ethilon. Heparinized saline was attached to the side ports of each sheaths at 30 mL per hour. TPA was administered through each infusion catheter at 0.5 mg per hour.Â
Biodiscs were placed at each puncture site and a sterile dressing was applied.
No immediate complication occurred, and the patient was discharged from the angiography suite in satisfactory condition.
FINDINGS:
- There is no ileocaval thrombus.
- There are single renal veins bilaterally. The IVC is normal in caliber. There is no aberrant anatomy.
- The filter is appropriately positioned below the lowest renal vein.
- The right vein is ultrasonographically patent and compresses. Needle entry was documented. Images were stored to PACS.
- Both infusion catheters are appropriately positioned within the lower lobe pulmonary arteries. The infusion catheter lengths extends through the course of the main pulmonary artery to the lower lobe pulmonary arteries.
IMPRESSION:
- No evidence for ileocaval thrombus.
- Uneventful image guided placement of an infrarenal Cook Celect IVC filter as described.
- Successful placement of bilateral pulmonary artery infusion catheters for catheter directed thrombolysis of pulmonary emboli.
The patient will be scheduled in Dr. ____ clinic in approximately 3 months for discussion of filter removal.