Single-session catheter-directed lysis using adjunctive clot fragmentation with power pulse spray only is a fast, safe, and effective option for acute pulmonary embolism

OBJECTIVE

Single-session, catheter-directed thrombolysis (CDT) with adjunctive power pulse spray (PPS) only, without thrombectomy, was evaluated for its safety and effectiveness. We performed a single-center, retrospective analysis of prospectively collected data.

METHODS

Patients with high-risk or intermediate-risk pulmonary embolism (PE) who met the inclusion criteria and underwent a single session of CDT-PPS were included in the study. The primary outcomes assessed were technical and clinical success and major adverse events. Secondary outcomes included effectiveness based on pre- and postintervention clinical examination, radiographic findings, and reversal of right ventricular dysfunction at 48 hours and 4 weeks after discharge on echocardiography and computed tomography pulmonary angiography. The length of stay in the intensive care unit and overall admission were also analyzed. A return to premorbid exercise tolerance was evaluated at 12 months after the procedure.

RESULTS

Between May 2016 and January 2023, 104 patients at the Wollongong Hospital were diagnosed with high- or intermediate-risk PE and underwent CDT-PPS. Of the 104 patients, 49 (47%) were considered to have high-risk PE and 55 (53%) intermediate-risk PE. Eleven patients (11%) had absolute contraindications and 49 patients (47%) had relative contraindications to systemic thrombolysis. Technical success was achieved in 102 patients (98%). Survival was 99% at 48 hours, 96% at 4 weeks, and 91% at 12 months. At 4 weeks, echocardiography showed 98% of patients had no evidence of right heart dysfunction, and computed tomography pulmonary angiography showed complete resolution of PE in 72%. There were no major adverse events at 48 hours. The median intensive care unit length of stay was 1 day, and the overall length of stay was 6 days. At 12 months, 96% had returned to their premorbid status.

CONCLUSIONS

The CDT-PPS technique is fast, safe, and effective in the treatment of high- and intermediate-risk PE, even in patients with a high bleeding risk, and should be considered as first-line management when the skills and resources are available. Further multicenter prospective studies are needed to corroborate these results.

Can Routine Investigation for Occult Pulmonary Embolism Be Justified in Patients with Deep Vein Thrombosis?

Purpose

This study aims to investigate whether routine screening for silent pulmonary embolism (PE) can be justified in patients with deep vein thrombosis (DVT).

Materials and Methods

We retrospectively analyzed the medical records of 201 patients with lower-extremity DVT admitted to the vascular surgery department of a single tertiary university center between 2019 and 2023. All patients underwent clinical evaluation, basic laboratory exams, a whole-leg colored duplex ultrasound, and a computed tomography pulmonary angiography (CTPA), to screen for an occult, underlying PE.

Results

The overall incidence of silent PE was 48.8%. The median admission D-dimer level was significantly higher in patients with silent PE than in those without PE (9.60 vs. 5.51 mg/L, P=0.001). A D-dimer value ≥5.14 mg/L was discriminant for predicting silent PE, with a sensitivity of 68.2% and a specificity of 59.3%. Silent PE was significantly more common on the right side, with the embolus located at the main pulmonary, lobar, segmental, and subsegmental arteries in 29.6%, 32.7%, 20.4%, and 17.3%, respectively. A higher incidence of occult PE was observed in patients with iliofemoral DVT (P=0.037), particularly when the thrombus extended to the inferior vena cava (P=0.003). Moreover, iliofemoral DVT was associated with a larger size and a more proximal location of the embolus (P=0.041). Multivariate logistic regression showed that male sex (odds ratio [OR]=2.46, 95% confidence interval [CI]: 1.39-3.53; P=0.026), cancer (OR=2.76, 95% CI: 1.45-4.07; P=0.017), previous venous thromboembolism (VTE) history (OR=2.67, 95% CI: 1.33-4.01; P=0.022), D-dimer value ≥5.14 mg/L (OR=2.24, 95% CI: 1.10-3.38; P=0.033), iliofemoral DVT (OR=2.13, 95% CI: 1.19-3.07; P=0.041), and thrombus extension to the IVC (OR=2.95, 95% CI: 1.43-4.47; P=0.009) served as independent predictors for silent PE.

Conclusion

A high incidence of silent PE was observed in patients with lower-extremity DVT. Screening of patients with DVT who have the aforementioned predictive risk factors using CTPA for silent PE may be needed and justified for the efficient management of VTE and its long-term complications.

Inferior vena cava filters: Concept review and summary of current guidelines

Anticoagulation is the first-line approach in the prevention and treatment of pulmonary embolism. In some instances, however, anticoagulation fails, or cannot be administered due to a high risk of bleeding. Inferior vena cava filters are metal alloy devices that mechanically trap emboli from the deep leg veins halting their transit to the pulmonary circulation, thus providing a mechanical alternative to anticoagulation in such conditions. The Greenfield filter was developed in 1973 and was later perfected to a model that could be inserted percutaneously. Since then, this model has been the reference standard. The current class I indication for this device includes absolute contraindication to anticoagulants in the presence of acute thromboembolism and recurrent thromboembolism despite adequate therapy. Additional indications have been more recently proposed, due to the development of removable filters and of progressively less invasive techniques. Although the use of inferior vena cava filters has solid theoretical advantages, clinical efficacy and adverse event profile are still unclear. This review analyzes the most important studies related to such devices, open issues, and current guideline recommendations.

Evidence-Based Update on Transcatheter Therapies for Pulmonary Embolism

PURPOSE OF REVIEW

Pulmonary embolism (PE) remains a leading cause of cardiovascular morbidity and mortality. Multiple new therapies are in development and under study to improve our contemporary care of patients with PE. We review and compare here these novel therapeutics and technologies.

RECENT FINDINGS

Multiple novel therapeutic devices have been developed and are under active study. This work has advanced the care of patients with intermediate and high-risk PE. Novel therapies are improving care of complex PE patients. These have inspired large multicenter international randomized controlled trials that are actively recruiting patients to advance the care of PE. These studies will work towards advancing guidelines for clinical care of patients with PE.

Causal effect of serum matrix metalloproteinase levels on venous thromboembolism: a Mendelian randomization study

Objectives

Serum matrix metalloproteinase (MMP) levels are associated with cardiovascular diseases. However, the causal associations between serum levels of specific MMPs and venous thromboembolism (VTE) remain unclear. The present study sought to explore the causal relationship between serum MMP levels and VTE by using the Mendelian randomization (MR) method.

Methods

In this study 2-sample MR study, the exposure data on serum MMP levels were derived from genome-wide association studies involving 21,758 individuals from 13 cohorts of European descent. The outcome data on VTE, including deep vein thrombosis and pulmonary embolism, were derived from the FinnGen research project. The primary method used was the inverse-variance weighting method. The MR-Egger intercept test and the Cochran Q test were used to evaluate pleiotropy and heterogeneity.

Results

Using the inverse-variance weighting method, higher serum MMP-12 levels were found to be associated with an increased risk of VTE (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; p=0.0015). Moreover, there was a weak association between the levels of certain MMPs and VTE. Sensitivity analyses revealed no significant heterogeneity and pleiotropy in our study, and the Steiger directionality test did not reveal a significant reverse causation association.

Conclusion

: There is a causal association between MMP-12 levels and VTE, which may have substantial implications for the diagnostic and therapeutic strategies used for VTE.

Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report

BACKGROUND

Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT.

CASE PRESENTATION

A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure.

CONCLUSIONS

Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.

Risk factors for suspected pulmonary embolism in children: Complication of Mycoplasma pneumoniae pneumonia

PURPOSE

Pulmonary embolism (PE) is not a rare complication of Mycoplasma pneumoniae pneumonia (MPP) in children. We sought to determine the incidence of PE in children with MPP who underwent clinically indicated CT pulmonary angiography (CTPA) and to evaluate the risk factors for PE.

METHODS

All 106 children with MPP who were clinically suspected of having PE and who underwent CTPA were retrospectively enrolled from June 2018 to December 2021. The clinical features, laboratory data, and radiological parameters were recorded (e.g., lung consolidation involved and the Qanadli score). A Cox proportional hazards model and area under the receiver operating characteristic (ROC) curve were used to evaluate the risk factors and prognostic discriminatory capacity for PE.

RESULTS

PE was detected in 26 of 106 (24.5 %) children (mean age, 6.2 years ± 3.3 years; 53 boys). Sixteen of the 26 (61.5 %) children with PE were boys. The mean age of the children with PE was 8.1 ± 2.9 years, and the mean Qanadli score was 15.3 ± 10.2. Children with PE had higher D-dimer levels (9.3 ± 7.1 mg/Lvs. 3.6 ± 3.8 mg/L) and a greater frequency of lung lobe consolidation (25 (96.2 %) vs. 64 (80.0 %)) (all P < 0.05). For children with MPP, age (hazard ratio (HR) = 1.96 (95 % CI1.04, 3.71; P = 0.037), D-dimer level (HR = 1.52, 95 % CI: 1.03, 2.24; P = 0.029), and bilateral lung consolidation (HR = 2.41, 95 % CI: 1.03, 5.58; P = 0.043) were found to be independent predictors of PE.

CONCLUSION

Clinical and CT radiological predictors could be used to predict PE in children with MPP. The use of risk factor assessment as a tool has the potential to guide more appropriate use of CTPA in children.

The Incidence of Pulmonary Embolism in Hospitalized Non-ICU Patients with COVID-19 during the First Wave: A Multicenter Retrospective Cohort Study in the Netherlands

INTRODUCTION

During the first COVID-19 outbreak in 2020 in the Netherlands, the incidence of pulmonary embolism (PE) appeared to be high in COVID-19 patients admitted to the intensive care unit (ICU). This study was performed to evaluate the incidence of PE during hospital stay in COVID-19 patients not admitted to the ICU.

METHODS

Data were retrospectively collected from 8 hospitals in the Netherlands. Patients admitted between February 27, 2020, and July 31, 2020, were included. Data extracted comprised clinical characteristics, medication use, first onset of COVID-19-related symptoms, admission date due to COVID-19, and date of PE diagnosis. Only polymerase chain reaction (PCR)-positive patients were included. All PEs were diagnosed with computed tomography pulmonary angiography (CTPA).

RESULTS

Data from 1,852 patients who were admitted to the hospital ward were collected. Forty patients (2.2%) were diagnosed with PE within 28 days following hospital admission. The median time to PE since admission was 4.5 days (IQR 0.0-9.0). In all 40 patients, PE was diagnosed within the first 2 weeks after hospital admission and for 22 (55%) patients within 2 weeks after onset of symptoms. Patient characteristics, pre-existing comorbidities, anticoagulant use, and laboratory parameters at admission were not related to the development of PE.

CONCLUSION

In this retrospective multicenter cohort study of 1,852 COVID-19 patients only admitted to the non-ICU wards, the incidence of CTPA-confirmed PE was 2.2% during the first 4 weeks after onset of symptoms and occurred exclusively within 2 weeks after hospital admission.

Catheter-based therapy for high-risk or intermediate-risk pulmonary embolism: death and re-hospitalization

BACKGROUND AND AIMS

Catheter-based therapies (CBTs) have been developed as a treatment option in patients with pulmonary embolism (PE). There remains a paucity of data to inform decision-making in patients with intermediate-risk or high-risk PE. The aim of this study was to characterize in-hospital and readmission outcomes in patients with intermediate-risk or high-risk PE treated with vs. without CBT in a large retrospective registry.

METHODS

Patients hospitalized with intermediate-risk or high-risk PE were identified using the 2017-20 National Readmission Database. In-hospital outcomes included death and bleeding and 30- and 90-day readmission outcomes including all-cause, venous thromboembolism (VTE)-related and bleeding-related readmissions. Inverse probability of treatment weighting (IPTW) was utilized to compare outcomes between CBT and no CBT.

RESULTS

A total of 14 903 [2076 (13.9%) with CBT] and 42 829 [8824 (20.6%) with CBT] patients with high-risk and intermediate-risk PE were included, respectively. Prior to IPTW, patients with CBT were younger and less likely to have cancer and cardiac arrest, receive systemic thrombolysis, or be on mechanical ventilation. In the IPTW logistic regression model, CBT was associated with lower odds of in-hospital death in high-risk [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.80-0.87] and intermediate-risk PE (OR 0.76, 95% CI 0.70-0.83). Patients with high-risk PE treated with CBT were associated with lower risk of 90-day all-cause [hazard ratio (HR) 0.77, 95% CI 0.71-0.83] and VTE (HR 0.46, 95% CI 0.34-0.63) readmission. Patients with intermediate-risk PE treated with CBT were associated with lower risk of 90-day all-cause (HR 0.75, 95% CI 0.72-0.79) and VTE (HR 0.66, 95% CI 0.57-0.76) readmission.

CONCLUSIONS

Among patients with high-risk or intermediate-risk PE, CBT was associated with lower in-hospital death and 90-day readmission. Prospective, randomized trials are needed to confirm these findings.

Venous thromboembolism chemical prophylaxis after skull base surgery

PURPOSE

There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis.

METHODS

Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons.

RESULTS

One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM.

CONCLUSION

Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

Evaluation of elevated serum apelin-13 and D-dimer concentrations in individuals diagnosed with pulmonary embolism

BACKGROUND

Given the limited specificity of D-dimer, there is a perceived need to discover a more precise marker for diagnosing individuals who are suspected of having pulmonary embolism (PE). In this study, by evaluating the increase in the serum level of Apelin-13 and D-dimer, we found valuable findings about Apelin-13, which can be suggested as an auxiliary and non-invasive diagnostic biomarker in individuals with suspected PE, based on the obtained results.

METHODS

In this case-control study, 52 Iranian individuals were included, all of whom were suspected to have PE. These individuals were then divided into two groups based on the results of CT angiography, which is considered the gold standard imaging method for diagnosing PE. The two groups were patients with PE and patients without PE. Finally, the levels of certain markers in the serum were compared between the two groups.

RESULTS

The mean serum D-dimer levels in patients with PE were significantly elevated (p < 0.001) in comparison to those without PE (1102.47 to 456.2 ng/ml). Furthermore, the mean level of Apelin-13 was significantly higher in patients with PE (49.8 to 73.11 ng/L) (p < 0.001). The cutoff point of Apelin-13 has been calculated at 58.50 ng/ml, with 90.9% sensitivity and 90% specificity. The D-dimer cutoff point was 500 ng/ml, with 95.5% sensitivity and 43.3% specificity.

CONCLUSIONS

Based on the results of this study, the serum level of Apelin-13 can be used as a novel diagnostic and screening biomarker in patients with pulmonary thromboembolism.

Drivers and recent trends of hospitalisation costs related to acute pulmonary embolism

BACKGROUND AND AIMS

The socio-economic burden imposed by acute pulmonary embolism (PE) on European healthcare systems is largely unknown. We sought to determine temporal trends and identify cost drivers of hospitalisation for PE in Germany.

METHODS AND RESULTS

We analysed the totality of reimbursed hospitalisation costs in Germany (G-DRG system) in the years 2016-2020. Overall, 484 884 PE hospitalisations were coded in this period. Direct hospital costs amounted to a median of 3572 (IQR, 2804 to 5869) euros, resulting in average total reimbursements of 710 million euros annually. Age, PE severity, comorbidities and in-hospital (particularly bleeding) complications were identified by multivariable logistic regression as significant cost drivers. Use of catheter-directed therapy (CDT) constantly increased (annual change in the absolute proportion of hospitalisations with CDT + 0.40% [95% CI + 0.32% to + 0.47%]; P < 0.001), and it more than doubled in the group of patients with severe PE (28% of the entire population) over time. Although CDT use was overall associated with increased hospitalisation costs, this association was no longer present (adjusted OR 1.02 [0.80-1.31]) in patients with severe PE and shock; this was related, at least in part, to a reduction in the median length of hospital stay (for 14.0 to 8.0 days).

CONCLUSIONS

We identified current and emerging cost drivers of hospitalisation for PE, focusing on severe disease and intermediate/high risk of an adverse early outcome. The present study may inform reimbursement decisions by policymakers and help to guide future health economic analysis of advanced treatment options for patients with PE.

Considerations for instituting pediatric pulmonary embolism response teams: A tool kit

The incidence of pediatric pulmonary embolism (PE) has increased by 200 % in the last decade, but at a single center, it is still infrequent. Given the unique epidemiologic features of pediatric PE, diagnosis is often delayed, and the management is empiric, based on individual physician experience or preference. Thus, there is a strong need for center-specific uniform management of pediatric PE patients. In adults, the development of pulmonary embolism response teams (PERTs) or PE critical care pathways has shortened the time to diagnosis and the initiation of definitive management. Evidence to support an improvement in PE outcomes after the development of PERTs does not exist in children. Nonetheless, we have summarized the practical practice guidelines that physicians and institutions can adopt to establish their institutional PERTs or critical pathways. We also provide strategies for resource-challenged institutions for partnering with centers with expertise in the management of pediatric PE.

Discrimination of the acute pulmonary embolism subtypes based on the novel MAPH score

Acute pulmonary embolism (APE) is a thromboembolism situation that can be central or peripheral. APE risk analysis and classification are essential for therapy planning. Our aim is to determine the novel MAPH score (including age, mean platelet volume (MPV), total protein, and hematocrit parameters) that can distinguish APE subtypes. Our retrospective cohort analysis includes 97 APE patients referred to the emergency medicine department who underwent pulmonary computed tomography angiography (CTA) in 24 h from 2020 to 2022. The hospital information system provided demographic, clinical, laboratory, and pulmonary CTA data. APE was classified into central (46 patients) and peripheral (51 patients) depending on the area of vascular involvement. The central APE group had higher hypertension (HT) (67.4%) and atrial fibrillation (AF) (39.1%) incidence than the peripheral APE group (all p values > 0.05). The central APE had higher total protein and platelet counts (p = 0.003 and p = 0.036), but peripheral APE had higher troponin values (p = 0.029). Central APE had 2.17 ± 0.85 MAPH and peripheral APE 1.76 ± 0.95 (p = 0.029). HT, AF, platelet count, and MAPH score differed significantly in univariate logistic regression (all p values < 0.05). However, only platelet count varied in multivariate logistic regression (p = 0.042). ROC curve analysis revealed that the MAPH score predicts central APE with 83% sensitivity and 45% specificity at a cut-off level of 1.5. The new MAPH score as an indicator of blood viscosity may distinguish between central and peripheral APE. Our result is significant, especially for centers with limited examinations, as it may accelerate the diagnosis and treatment processes. We think that our results might guide future investigations.

Postpartum dilated cardiomyopathy and antiphospholipid syndrome: A rare association revealed by a pulmonary embolism (case report)

Antiphospholipid syndrome is a rare entity that must be systematically evoked in front of recurrent miscarriages associated with venous or arterial thrombosis, its diagnosis is based on a set of clinico-biological arguments. In rare cases, it can be associated with postpartum cardiomyopathy, which is defined by a dysfunction of the left ventricle with an LVEF<45%, which may or may not be associated with a dilation of the left ventricle. This association is rare and poorly described in the literature, which makes management difficult and uncodified. In this context we report the case of a 33-year-old patient with cardiovascular risk factors such as arterial hypertension 2 previous miscarriages and repeated phlebitis, she was admitted to the emergency room for the management of acute dyspnea related to a proximal right pulmonary embolism and in whom the transthoracic echocardiography had objectivated a dilated left ventricle and an alteration of the ejection fraction of the left ventricle, the coronary angiography came back without particularity as part of the etiological work-up, a biological work-up was carried out, which came back in favor of an antiphospholipid syndrome. This case shows diagnostic difficulties and management of this disease.

Diagnostic strategies in postpartum individuals with suspected venous thromboembolism: A scoping review

BACKGROUND

The risk of venous thromboembolism (VTE) is increased postpartum and contributes to important morbidity and mortality. While there have been advances in evaluating diagnostic algorithms for suspected VTE during pregnancy, there is limited data for postpartum individuals.

OBJECTIVE

We conducted a scoping review to describe and evaluate diagnostic strategies used to investigate suspected VTE in postpartum individuals.

METHODS

A comprehensive search strategy was conducted in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (January 1, 2000-September 30, 2022) to identify original articles that reported on diagnostic strategies in postpartum individuals with suspected VTE. We extracted demographics, clinical decision rules used, D-dimer and imaging completed, including test performance and VTE outcomes.

RESULTS

A total of 13 studies conducted across 11 countries with separate postpartum data were included for 759 individuals with suspected PE (n = 634) or DVT (n = 125), including unpublished data (n = 251). Among those with suspected PE, computed tomography pulmonary angiography was conducted more commonly (n = 522) than ventilation-perfusion scans (n = 69), with PE positivity rates that ranged from 4 %-27.6 % and 0-50 % across studies, respectively. Among 131 postpartum individuals with suspected PE who had a D-dimer measured, only 4.6 % (6/131) had a negative D-dimer test. For postpartum individuals with suspected DVT, the most common diagnostic test was compression ultrasonography (positivity rate 12.2 %-18.6 %). There were limited retrospective data evaluating the clinical decision rules.

CONCLUSIONS

There are heterogeneous approaches globally in the diagnosis of suspected postpartum VTE. Limited high-quality data available underscores the need for more robust evidence to inform clinical practice.

Dust particulate matter increases pulmonary embolism onset: A nationwide time-stratified case-crossover study in China

BACKGROUND

Particulate matter (PM) has been found to elevate the risk of pulmonary embolism (PE) onset. Among the contributors to PM, dust PM stands as the second natural source, and its emissions are escalating due to climate change. Despite this, information on the effect of dust PM on PE onset is scarce. Hence, this study aims to investigate the impacts of dust PM10, dust PM2.5-10, and dust PM2.5 on PE onset.

METHODS

A nationwide time-stratified case-crossover study was conducted between 2015 and 2020, using data from 18,616 PE onset cases across 1,921 hospitals in China. The analysis employed a conditional logistic regression model to quantify the associations between dust PM10, dust PM2.5-10, and dust PM2.5 and PE onset. Furthermore, the study explored the time-distributed lag pattern of the effect of dust PM on PE development. Stratified analyses were performed based on sex, age, region, and season.

RESULTS

Dust PM10, dust PM2.5-10, and dust PM2.5 exhibited significant health effects on PE onset, particularly concerning exposure on the same day. The peak estimates were observed at lag 01 day, with the odds ratio being 1.011 [95 % confidence interval (CI): 1.003, 1.019], 1.014 (95 % CI: 1.003, 1.026), and 1.039 (95 % CI: 1.011, 1.068), for a 10 μg/m3 increase in the concentration of dust PM10, dust PM2.5-10, and dust PM2.5, respectively. In addition, the study identified a higher risk of PE onset associated with dust PM exposure during the warm season than that in cool season, particularly for dust PM2.5.

CONCLUSIONS

The findings from this study suggest that short-term exposure to dust PM, particularly dust PM2.5, may trigger PE onset, posing a significant health threat. Implementing measures to mitigate dust PM emissions and protect patients with PE from dust PM exposure is imperative.

A multidisciplinary pulmonary embolism response team (PERT): first experience from a single center in Germany

BACKGROUND

Over the last few years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in managing acute pulmonary embolism (PE).

PURPOSE

To investigate PERT's composition and added clinical value in a university center in Germany.

METHODS

Over 4 years (01/2019-11/2022), patients with confirmed PE were enrolled in a prospective single-center cohort study (PERT Mainz). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE before and after the initiation of PERT at our Medical University Centre. The primary outcome was in-hospital PE-related mortality.

RESULTS

From 2019 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a median age of 68; 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 76.1% of all patients. In total, 42.0% were classified as intermediate-high-risk PE and 11.4% as high-risk PE. First PERT contact mainly originated from emergency departments (33.3%) and intensive care units (30.0%), followed by chest pain units (21.3%) and regular wards (12.0%). The participation rate of medical specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT consultations, followed by radiologists (95.9%) and anesthesiologists (87.8%). Compared to the PERT era, more patients in the pre-PERT era were classified as simplified pulmonary embolism severity index (sPESI) ≥ 1 (78.4% vs 71.6%) and as high-risk PE according to ESC 2019 guidelines (18.2% vs. 11.4%). In the pre-PERT era, low- and intermediate-low patients with PE received more frequently advanced reperfusion therapies such as systemic thrombolysis or surgical embolectomy compared to the PERT era (10.7% vs. 2.5%). Patients in the pre-PERT were found to have a considerably higher all-cause mortality and PE-related mortality rate (31.8% vs. 14.8%) compared to patients in the PERT era (22.7% vs. 13.6%). After propensity matching (1:1) by including parameters as age, sex, sPESI, and ESC risk classes, univariate regression analyses demonstrated that the PE management based on a PERT decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p = 0.009). For PE-related mortality, a tendency for reduction was observed (OR, 0.54 [95%CI 0.24-1.18]; p = 0.121).

CONCLUSION

PERT implementation was associated with a lower risk of all-cause mortality rate in patients with acute PE. Large prospective studies are needed further to explore the impact of PERTs on clinical outcomes.

Comparison of inferior vena cava filter use and outcomes between cancer and non-cancer patients in a tertiary hospital

BACKGROUND

While accepted indications for the use of inferior vena cava filter (IVCF) in patients with a venous thromboembolism (VTE) have remained stable, their use continues to be frequent. Retrieval rates are still low, being particularly notable in the population with cancer. This study aims to review the rate of adherence to guidelines recommendation and to compare retrieval rates and complications in both cancer and non-cancer patients.

METHODS

A retrospective study was performed including 185 patients in whom an IVCF was placed in Hospital Clinic of Barcelona. Baseline characteristics, clinical outcomes, and IVCF-related outcomes were analyzed. A strongly recommended indication (SRI) was considered if it was included in all the revised clinical guidelines and non-strongly if it was included in only some.

RESULTS

Overall, 47 % of the patients had a SRI, without differences between groups. IVCF placement after 29 days from the VTE event was more frequent in the cancer group (46.1 vs. 17.7 %). Patients with cancer (48.1 % of the cohort) were older, with higher co-morbidity and bleeding risk. Anticoagulation resumption (75.3 % vs. 92.7 %) and IVCF retrieval (50.6 % vs. 66.7 %) were significantly less frequent in cancer patients. No significant differences were found regarding IVCF-related complications, hemorrhagic events and VTE recurrence.

CONCLUSIONS

SRI of IVCF placement was found in less than half of the patients. Cancer patients had higher rates of IVCF placement without indication and lower anticoagulation resumption and IVCF retrieval ratios, despite complications were similar in both groups.

[Maternal mortality due to venous thromboembolism in France 2016-2018]

Pregnancy and the post-partum period represent a thromboembolic risk situation, with pulmonary embolism (PE) remaining one of the leading causes of direct maternal deaths in developed countries. Between 2016 and 2018 in France, twenty maternal deaths were caused by venous thromboembolic complications (VTE), yielding a Maternal Mortality Ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3), with no change compared to the periods 2013-2015 or 2010-2012. Among these 20 deaths, 1 death was related to cerebral thrombophlebitis, and the remaining 19 were due to PE. Regarding the timing of death, 2 deaths occurred after an early termination of pregnancy, 40% (8/20) during an ongoing pregnancy, and 50% (10/20) in the post-partum period. Among the 20 VTE deaths, 20% (4/20) occurred outside of a healthcare facility (at home or in a public place). Among the nineteen cases with documented BMI, seven women had obesity (37%), three times more than in the population of parturients in France (11.8%, ENP 2016). Among the nineteen PE deaths and the case of cerebral thrombophlebitis, eleven were considered preventable, six possibly preventable (35%), two probably preventable (12%), and three preventability undetermined. The identified preventability factors were inadequate care and the patient's failure to interact with the healthcare system. From the case analysis, areas for improvement were identified, including insufficient consideration of major and minor risk factors, the early initiation of appropriate prophylactic treatment, and the absence of fibrinolysis in cases of s refractory cardiac arrest due to suspected PE.

A case of endovascular treatment for iatrogenic left vertebral artery injury due to central line catheter placement

We describe a case of endovascular treatment for an iatrogenic left vertebral artery injury after central line catheter placement in a 68-year-old male patient. The patient had a massive pulmonary embolism, and a Swan-Ganz catheter was required to monitor the patient's circulatory condition. However, the catheter was inserted into the left vertebral artery and passed through the left internal jugular vein. Endovascular treatment was indicated due to the patient's poor general health. Complete hemostasis was achieved, and the postoperative course was uneventful without neurologic deficits.

Prediction of mortality in acute pulmonary embolism in cancer-associated thrombosis (MAUPE-C): derivation and validation of a multivariable model

Optimal risk stratification of patients with cancer and pulmonary embolism (PE) remains unclear. We constructed a clinical prediction rule (CPR) named 'MAUPE-C' to identify patients with low 30 days mortality. The study retrospectively developed and internally validated a CPR for 30 days mortality in a cohort of patients with cancer and PE (both suspected and unsuspected). Candidate variables were chosen based on the EPIPHANY study, which categorized patients into 3 groups based on symptoms, signs, suspicion and patient setting at PE diagnosis. The performance of 'MAUPE-C' was compared to RIETE and sPESI scores. Univariate analysis confirmed that the presence of symptoms, signs, suspicion and inpatient diagnosis were associated with 30 days mortality. Multivariable logistic regression analysis led to the exclusion of symptoms as predictive variable. 'MAUPE-C' was developed by assigning weights to risk factors related to the β coefficient, yielding a score range of 0 to 4.5. After receiver operating characteristic (ROC) curve analysis, a cutoff point was established at ≤ 1. Prognostic accuracy was good with an area under the curve (AUC) of 0.77 (95% CI 0.71-0.82), outperforming RIETE and sPESI scores in this cohort (AUC of 0.64 [95% CI 0.57-0.71] and 0.57 [95% CI 0.49-0.65], respectively). Forty-five per cent of patients were classified as low risk and experienced a 2.79% 30 days mortality. MAUPE-C has good prognostic accuracy in identifying patients at low risk of 30 days mortality. This CPR could help physicians select patients for early discharge.

Renal cell carcinoma with massive cavo-atrial tumor thrombus leading to pulmonary embolism: Case study and literature review

INTRODUCTION

Renal cell carcinoma (RCC) occasionally involves the inferior vena cava (IVC), but intra-atrial extension is very rare, with the most dreaded complication being thrombi migration into pulmonary arteries.

CASE PRESENTATION

A 52-year-old male with rheumatoid arthritis and a smoking history presented with dyspnea, weight loss, and a previous episode of hematuria. Echocardiography revealed an intra-atrial thrombus with signs of pulmonary embolism (PE). Subsequent evaluation found a massive right renal tumor with an extensive thrombus extending into the right atrium, causing PE. Multidisciplinary management included surgery involving nephrectomy and thrombectomy via cavotomy and open-heart surgery along with pre- and postoperative anticoagulation.

DISCUSSION

Intra-caval tumor thrombus (TT) in RCC is infrequent, especially when extending into the right atrium. Accurate diagnosis involves imaging modalities, with echocardiography and MRI playing pivotal roles. Multidisciplinary and personalized management is mandatory to ensure a successful outcome. Surgery remains the primary treatment for RCC with TT but carries significant risks.

CONCLUSION

Managing RCC with cavo-atrial tumor thrombus is a complex situation that requires a collaborative approach. Accurate staging and tailored treatment are crucial. Surgical intervention remains pivotal in the absence of alternative effective modalities. Ongoing research into adjuvant therapies is crucial for optimal outcomes.