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Institut Mutualiste Montsouris Paris, France Hôpital Antoine Béclère Clamart, France
To the Editor:
We read with interest Dr. Goldhaber's editorial on catheter thrombectomy for treating severe pulmonary embolism in the November issue of CHEST.1 However, we do not share his enthusiasm. We do not believe that mechanical fragmentation of pulmonary emboli, as described in the careful and detailed report by Schmitz-Rode and colleagues2 in the same CHEST issue, has been shown to provide any clinical benefit to patients with severe pulmonary embolism. In that study, like in virtually all published series on the same subject, most patients, if not all (8 of 10 patients in the report from Schmitz-Rode and colleagues) received medical thrombolysis together with mechanical fragmentation, so that at the very least, and as was acknowledged by the authors, the respective efficacy of each technique in the observed results cannot be assessed. Several investigators have demonstrated the dramatic and rapid (within 60 min) improvement of mean pulmonary artery pressure and cardiac index, resulting in a highly significant decrease in pulmonary vascular resistance after a simple bolus IV infusion of urokinase or alteplase in patients with severe acute pulmonary embolism.3 ,4 ,5
Even from a theoretical point of view, the fragmentation of a sphere of 1 cm3 into 1,000 spheres of 1 mm3 would transform a cross-sectional obstruction of 1 cm2 into a cross-sectional obstruction of 10 cm2, ie, a proximal occlusion into a more distal but larger occlusion, with likely similar, if not worse, hemodynamic consequences. The supposed improvement in the efficacy of medical thrombolysis when applied to smaller clots remains to be demonstrated.
Thus, convincing arguments, either clinical or theoretical, to support the view that mechanical fragmentation of pulmonary emboli provides any clinical benefit over mere anticoagulant treatment and/or medical thrombolysis are lacking. In view of its cost and possible complications, including hemorrhagic complications of vascular access in patients who may receive thrombolytic agents, the addition of this aggressive technique should not be recommended, and catheter fragmentation of pulmonary emboli should not be "integrated into our armamentarium to treat acute pulmonary embolism" until careful clinical trials have clearly demonstrated its clinical efficacy.
Correspondence to: Philippe Girard, MD, FCCP, Département Thoracique, Institut Mutualiste Montsouris, Choisy 6, Place de Port au Prince, 75013 Paris, France; e-mail: pgirard@imm.fr
References
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