Figure 3.

Percutaneous thrombectomy procedure: A 5 French pigtail catheter was inserted over a 0.035 Bentson wire and its tip advanced selecting the main pulmonary artery. The sheath was advanced over Amplatz wire 0.035 Inch with its tip in the right pulmonary and an angiogram with 10 ml/sec of 20 ml Omnipaque contrast was performed from this position. These injection rates and volumes were used during all remaining angiograms. A) The right pulmonary angiogram, before the alteplase thrombolysis/mechanical thrombectomy, showed large filling defect in the main right pulmonary artery with poor right pulmonary perfusion (arrows pointing at hypoperfused upper and lower right lung arteries). Pressure in the main pulmonary artery, before the alteplase thrombolysis/ mechanical thrombectomy, was 39/19 with mean of 24 mm Hg. At this point, right pulmonary catheter-directed thrombolysis using 6 mg of alteplase diluted in 10 ml sterile water injected over 2 minutes was performed. Right pulmonary mechanical thrombolysis using rotational pigtail (5 French) catheter was then performed under fluoroscopic guidance and cardiopulmonary monitoring. B) Right upper lobe pulmonary mechanical thrombolysis using the Cleaner^TM Argon device (arrow) was performed under fluoroscopic guidance and cardiopulmonary monitoring. C) Right pulmonary angiogram showing improved perfusion of right upper pulmonary arteries (arrow) D) Dark clotted blood was removed via the aspiration catheter in the amount of 70 ml E) Right lower lobe pulmonary mechanical thrombolysis using the Cleaner device (arrow) under fluoroscopic guidance and cardiopulmonary monitoring F) Completion right pulmonary angiogram after the alteplase thrombolysis/ mechanical thrombectomy, showing significant decrease in the filling defect in the right lower pulmonary arteries. Respiratory and heart rates were improved and the pressure in the main pulmonary artery, after the alteplase thrombolysis/ mechanical thrombectomy, was 28/12 with mean of 19 mm Hg.