William Magnuson had just come back inside his Glenwood, Iowa, home after taking the trash out in late March when the world started spinning.
He walked into the living room and told his daughter that he needed to sit down. He still didn’t feel well, so he decided to go lie down in a bedroom.
The next thing he knew, he was lying on the floor, his wife telling him not to get up. Emergency responders checked him out, and his wife took him to Jennie Edmundson Hospital in Council Bluffs. There, doctors discovered a blood clot — a pulmonary embolism — in an artery leading to his lung.
The next morning, Dr. John Park, a vascular surgeon with Methodist Health System, inserted catheters into veins in his groin, wove them through his heart and into the pulmonary arteries and the clot.
For the next 12 hours, the catheters dripped clot-busting drugs into the clot and emitted high-frequency ultrasound pulses believed to help loosen fibers and help the drugs work faster.
Nearly five months later, Magnuson, 68, a retired teacher, is back at his summer job — his 29th summer — weed-whacking and mowing at the Glenwood Cemetery.
“I’m very blessed to be here,” said Magnuson, who was in good health and took no medications before his scare.
The device Park used, the EkoSonic Endovascular System, or EKOS, is one of a number of tools doctors now have to detect and treat pulmonary embolisms.
Pulmonary embolisms are caused by clots that form elsewhere in the body — often the legs — and then break off and travel to the pulmonary arteries. They’re the ones that carry oxygen-spent blood coming in from the veins over to the lungs to pick up oxygen.
The embolisms fall along a spectrum, from the many small ones that break down without causing any problems to massive ones that cause a blockage significant enough to shut down the whole cardiac system. The American Heart Association reports that 339,000 pulmonary embolisms were diagnosed in 2014, the most recent year data was available.
Some can be deadly — federal estimates indicate 20 percent or more of pulmonary embolisms result in sudden death.
In the past two decades, there have been increased efforts to target the problem, including a significant push on prevention in hospitals — surgery, injury and childbirth are among risk factors — and a call to action by the U.S. Surgeon General.
To make treatment more systematic, Methodist, like a number of institutions nationwide, has created a multidisciplinary pulmonary embolism response team to treat such patients, similar to the stroke teams in many hospitals.
Nebraska Medicine is working on the specifics of such a team. Bryan Heart in Lincoln also is looking at creating a team.
For the massive ones, there are a number of potential interventions, including anti-clotting drugs. Doctors also can give clot-busting drugs intravenously so it goes throughout the system or use catheters to drip it inside clots. Doctors also have explored clot-retrieving or clot-sucking devices similar to those used in strokes.
Then there are the ones in the middle, like Magnuson’s.
In the past, Park said, doctors typically gave such patients anti-clotting drugs to prevent more clots from forming. They might continue taking such drugs at home. Then it was largely up to the body to dissolve the remaining clot as best it could. Within a week or two, however, those clots start to turn fibrous, making them more difficult to break down.
In the meantime, the heart has to pump harder to push blood around the obstruction. Eventually, the extra work of pumping can damage the heart. Depending on the case, patients may be short of breath, unable to exercise or do what they used to do, Park said.
So doctors began using catheters to drip the clot-busting drugs into some of those patients. The idea is to dissolve the clot before it can harm the heart.
“We can treat those people early so that the damage doesn’t occur and is not permanent,” Park said.
Using catheters to deliver the drugs directly to the clot requires less drug over a longer period of time than giving a larger systemic dose, he said. The large dose comes with a risk of serious bleeding.
The EKOS system adds ultrasound to the dripped-in clot-buster mix.
Park said there is still some debate about which patients in the middle category of pulmonary embolisms will benefit from the treatment. Some studies still are under way.
“The idea is, who do we treat and when do we treat,” he said, “and that’s the crux of the problem.”
Dr. Katherine Brown, a vascular surgeon with Omaha Thoracic and Cardiovascular Surgery , said the catheter-directed treatments help improve symptoms such as shortness of breath. Studies also show they improve function in the right side of the heart. Her private practice performs the procedure at Creighton University Medical Center-Bergan Mercy.
The final word — seeing how well those patients do over the long term, compared with current treatments — isn’t yet in, she said. Studies don’t yet go out far enough.
Brown also stressed that patients have to get the treatment soon after the embolism occurs. It’s not one they can come back for a year later.
Dr. Joe McBride, a vascular and interventional radiologist with Nebraska Medicine, said he and his colleagues use EKOS and a number of other tools and techniques to treat pulmonary embolisms. In the end, decisions on how to treat patients are made on a case-by-case basis.
“There are more options out there than there were 15 to 20 years ago for treating these large clots that might be life-threatening or life-limiting,” he said.
Dr. Matthew Johnson, an interventional cardiologist at Bryan Heart, said he and his colleagues have used EKOS in the lungs in the past and are looking at expanding that practice, based on new data that’s come out in the past year.
Magnuson, the retired Iowa teacher, said he didn’t know how serious his situation was until he saw his regular doctor a short time later. At the hospital, he chatted with a number of former students, including several nurses and the head of the catheterization lab. The afternoon after the procedure, he walked out of the hospital.
“It’s a procedure people need to know about,” Magnuson said. “There is something out there that can help you.”