Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis Saim Sag 1 • Omer Fatih Nas 2 • Aysel Aydin Kaderli 1 • Bulent Ozdemir 1 • I ˙ brahim Baran 1 • Cuneyt Erdog˘an 2 • Sumeyye Gullulu 1 • Bahattin Hakyemez 2 • Ali Aydinlar 1 Ó Springer Science+Business Media New York 2016 Abstract The treatment options for high risk acute pul- monary embolism (PE) patients with failed systemic thrombolytic treatment (STT) is limited. The clinical use of catheter directed thrombolysis with the EkoSonic Endovascular System (EKOS) in this population has not been evaluated before. Catheter directed thrombolysis is an effective treatment modality for high risk PE patients with failed STT. Thirteen consecutive patients with failed STT were included in the study. EKOS catheters were placed and tissue plasminogen activator (t-PA) in combination with unfractionated heparin were given. Clinical and echocardiographic properties of the patients were collected before EKOS, at the end of EKOS and during the follow-up visit 6 months after discharge. The duration of EKOS treatment was 21.8 ± 3.8 h and the total dose of tPA was 31.2 ± 15.3 mg. One patient who presented with cardiac arrest died and the clinical status of the remaining subjects improved significantly. Any hemorrhagic complication was not observed. EKOS resulted in significant improvement of right ventricular functions and decrease of systolic pul- monary artery pressure. During a follow-up period of 6 months none of the patients died or suffered recurrent PE. In addition, echocardiographic parameters or right ventricular function significantly got better compared to in- hospital measurements. EKOS is an effective treatment modality for high risk PE patients with failed STT and can be applied with very low hemorrhagic complications. Keywords Acute pulmonary embolism Á Failed systemic thrombolytic treatment Á Catheter directed thrombolysis Á EkoSonic Endovascular System Introduction Acute pulmonary embolism (APE) is a common clinical presentation of venous thromboembolism and mortality rates exceeding 15 % have been reported, especially in patients presenting with massive PE, cardiogenic shock or right ventricular failure [1]. Systemic thrombolytic treat- ment (STT) is effective in restoration of the hemodynamic status and right ventricular functions. However, STT increases hemorrhagic complications with reported rates of 20 % for major hemorrhage and 2.2 % for intracranial hemorrhage [1]. Even if, controversy goes on about the mortality benefit of STT in APE patients, it is strongly recommended in patients with massive APE [1–3]. In 8 % of patients, STT is ineffective and rescue surgical embolectomy or repeat STT may be tried in these patients [4]. Catheter directed therapies (CDT) are promising in this population but the effectiveness of these therapies has been investigated only in a few studies [5, 6]. The EkoSonic Endovascular System (EKOS Corpora- tion; Bothell, WA, USA) is a catheter system for intravascular ultrasound-assisted thrombolysis. It combines a multi-side hole drug infusion catheter with a multi-ele- ment ultrasound core wire [7]. The effectiveness of EKOS has been investigated in APE patients with low complica- tion rates but the study populations are heterogeneous and a comparative study of this technique with STT or surgical embolectomy has not been performed [8–10]. In addition, the subgroup of APE patients who might gain the most benefit from EKOS therapy has not been well established. & Saim Sag saimsag@gmail.com 1 Department of Cardiology, Uludag University Medical School, 16059 Bursa, Turkey 2 Department of Radiology, Uludag University School of Medicine, 16059 Bursa, Turkey 123 J Thromb Thrombolysis DOI 10.1007/s11239-016-1370-3