Most PA procedures

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For example for L PA pseudoaneurysm after gunshot 

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Can access via R CFV

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Can use 6F long 45 cm or 60 cm sheath and can curve sheath

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to get into Pulmonary arteries

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use 6F Montifiore catheter

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and use exchange length bentson

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basically just wiggle catheter into RA and then into PA outflow tract

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when you push the wire out, it tends to prolapse into the PA

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actually somewhat straightfoward

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after that can exchange over betnson for angled cath, either kumpe 65-80 or angled glidecath or glideCobra

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remember to use all angulations to see PA better, RAO, LAO and cranio caudad angulation

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have fun

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did a PA AVF 

RLL PA connection to draining vein leading to LA

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whoel case like this:

R groin access, CFV

all exch length wires, long bentson

tracked 7F 50 cm or so sheath to RA

used 7F? grollman catheter to wiggle up through PA into RPA

tracked sheath over catheter

used wire at times

left wire in the rPA

used long 100 cm angled cath merit medical to select the RPA, the lower lobe and then the feeder vessel

got out as distal as possible using bentson and angled cathete

did some angiography

tracked sheath as distal as possible

got as closeto nidus as possible (where artery turns into pulmonary vein)

put big occlusion device there, large MVP4 device, which goes thru catheter

then followed it with large 035 pushable coils x 3

post embo run no flow

pulled all and left

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thats it

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PA Lysis

 

for intermediate risk PE

with JM

 

R CFV access x 2

 

use micrpunc upsize to 7F 55 cm sheath

use exch length everything

exch length bentson

use pigtail or grollman or montefiore to get into PA

can be difficult

watch for ectopy

once in, track sheath as close you can get into PA

do run thorugh sheath or catheter

do oblique imaging

get wire into LPA and then stick again and get wire into RPA

can switch wire for exch amplatz to track sheaths up

eventually advance infusion catheter long length over wire into PA

remove wire and place obturator into infusion caths

stich sheath into place

use steristrips to get infusion cath into place

start drips

make nice dressing for pt leg

 

pt to remain bedrest while drips are infusing

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PA lysis catheter check

remember check pressures

remove unifuse over long bentson

advance and form pigtail flush into each PA

measure pressures and record

do flush angiogram of each PA

decide if to continue or not

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Supplies for PA lysis:
 

Remember to order urinary catheter

need orders for pre, during, and post

make sure to have lytic and heparin bags ordered and obtained from pharmacy

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think about IVCF placement

MAKE SURE TO PLACE PICC LINE DURING LYSIS;  for frequent blood draws of fibrinogen 

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55 cm 7F Cook sheath x2

micropuncture kit

exch length bentson

exch length amplaz (regular stiff Green wire)

montiefiore or other PA catheter 7F

100 cm 5F pigtail catheter (can be the best PA cath actually, for nego into PAs)

100 cm 5F angled / vert catheter (merit makes one)

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stick R CFV or R SFV twice and place two sheaths to start

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consider dilators for access cuz of kinking at the site difficulty advancing long 7F sheaths

90 cm 10 cm infusion length Unifuse catheters

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when doing Runs, do one AP and one 30deg LAO

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ok to run 1 mg TPA x2 infusions catheters

ok to run 400 U heparin x2 for 2 sheaths

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check fibrinogen q6 hrs, 150 is cutoff value

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think about IVCF.  if placing, would place initially, then drive seaths up thru

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prelim checklist for PA lysis consult:

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first off what type of PE? mild mod sev, garden variety, submassive, massive

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massive means hypotension systolic 90 mm x 15 min or reduction in baseline pressure some ?x amount x some amt time

tachycardia

pressors can mean unstable

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submassive means normotensive but evidence of RHstrain

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garden variety is low risk:  DVT and PE and will get better on a/c, probably as outpt

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info you want:

cardiac enzymes:  trop leak? many causes of this including MI, inflammation

cardiac echo:  is there RH dysf?  

EKG:  is there s1q3t3?  is there RBBB?  is it normal abn?  is there STEMI?

BNP: can be helpful if acutely up- may mean RH dysf

CTA:  check RV / LV ration:  if greater than 0.9: indicates RH strain.  check for thrombus in situ within cava:  IVCF.  check for CTEPH

get a baseline DIC panel- for ddimer and fibrinogen

get arterial or venous lactate

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is there PERT team

is there cardiology

is cardiac surgery avail

contra indication to lytics?

age - older is worser- more brain bleeds

is there recent surgery?

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alternative to catheter based lysis is IV alteplase

can use 100 mg IV or 'half dose' 50 mg alteplase

can still do lysis afterwards

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