https://doi.org/10.1007/s00392-025-02737-x
1Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; 2Schön Klinik Neustadt Klink für Innere Medizin und Kardiologie Neustadt in Holstein, Deutschland; 3Asklepios Westklinikum Rissen Abteilung für Kardiologie Hamburg, Deutschland
Background:
The EkoSonic™ Endovascular System (EKOS) is currently one of the most widely used catheter-directed therapies (CDT) for treatment of intermediate-high and high-risk pulmonary embolism (PE). While femoral access is the standard approach, it is associated with a notable risk of bleeding complications. Given the small catheter diameter (5.4 Fr), brachial access may represent a safe and effective alternative, particularly in patients where femoral access is limited. However, clinical data supporting the use of brachial access for EKOS thrombolysis is limited.
Aim:
To assess the efficacy and safety of EKOS thrombolysis performed via brachial access, with particular focus on access type, technical feasibility, procedural safety, and potential advantages in selected patients.
Methods:
This retrospective dual-center study analyzed consecutive patients with intermediate-high or high-risk PE treated with EKOS thrombolysis between 08/2023 and 05/2025 at University Heart Center Lübeck - UKSH Lübeck and Schoen Clinic Neustadt. Vascular access included unilateral or bilateral brachial vein or combined brachial-femoral/jugular routes.
The brachial approach was primarily chosen in patients with obesity, femoral vein thrombosis, or prior femoral access. Access type and catheter length were documented.
Safety was assessed via complication rates, and efficacy was evaluated by changes in echocardiographic parameters before and after the procedure.
Results:
Twenty-seven consecutive patients (63% female) were enrolled. 41% were performed via unilateral cubital vein, 44.4% bilateral on contralateral cubital veins, combined brachial with either femoral or jugular access was performed respectively in 7.4%.
Overall mean age was 64.7 ± 12 years and patients were obese with a mean BMI 33.5 ± 8.1 kg/m2. Most common risk factor was smoking seen in 22.2% of the patients. 30% had a deep vein thrombosis.
Catheter sizes varied by operator and availability, with 22 (81.5%) using 106×12 cm, 3 (11.1%) using 135×12 cm, and 2 (7.4%) using 106×18 cm catheters. Documented complications included hematoma (3.7%), ventricular fibrillation during insertion of EKOS-catheter (3.7%), and device malfunction (3.7%) leading to only unilateral lysis. No major bleeding or procedure-related mortality occurred.
Echocardiography demonstrated significant haemodynamic improvements. The RV/LV ratio decreased from 1.14 ± 0.2 to 0.9 ± 0.2. Systolic pulmonary artery pressure dropped from 51.3 ± 10 to 34 ± 12 mmHg. Tricuspid annular plane systolic excursion improved from 16.5 ± 3 mm to 22.4 ± 4 mm.
Conclusion:
In our analysis, brachial access for EKOS-guided thrombolysis proved to be safe, technically feasible, and effective. The brachial approach may offer practical advantages, including a superficial vein position that reduces the risk of accidental arterial puncture, allows faster bleeding control and easier access, particularly in obese patients.
Additional benefits include the possibility of dual access at the same site for bilateral PE treatment, which contributes to greater patient comfort by allowing more comfortable mobility compared to femoral access.
Given these findings, brachial access represents a promising alternative, especially when femoral access is limited or unfavorable. Further prospective randomized studies are needed to further validate these findings and to directly compare the safety and efficacy of different vascular access routes.