Management of Massive Pulmonary Embolism

Successful use of extracorporeal membrane oxygenation in a patient with combined pulmonary and systemic embolisation

We present a highly unusual case of massive pulmonary embolism with secondary paradoxical systemic embolisation that was successfully resuscitated with veno-arterial extracorporeal membrane oxygenation (ECMO). This enabled subsequent successful bridging to pulmonary embolectomy.

Right ventricular responses to massive and submassive pulmonary embolism

It is critically important to quickly recognize and treat acute pulmonary embolism (PE). Submassive and massive PEs are associated with right ventricular (RV) dysfunction and may culminate in RV failure, cardiac arrest, and death. A rapid and coordinated diagnostic and management approach can maximize success and save lives.

Pulmonary embolism in the emergency department: a Singaporean nursing case review

INTRODUCTION

The presentation of pulmonary embolism to the emergency department (ED) can prove challenging because of the myriad of potential disease processes that mimic its signs and symptoms. The incidence of pulmonary embolism and indeed the mortality associated with it is relatively high. Early diagnosis and treatment is crucial in off-setting the potential deleterious effects associated with this condition. The aim of this article is to present a nursing case review of a patient presenting to the ED with a diagnosis of pulmonary embolism.

METHOD

We chose to use a case review to highlight the nursing and medical care that was provided for a patient who presented to the emergency department acutely with dyspnoea, chest pain and pyrexia. The use of case reviews are useful in reporting unusual or rare cases and this format is typically seen more in medicine than in nursing. They can naturally take one of two formats-a single case report or a series of case reports; in this case we opted to report on a single case.

DISCUSSION

The gentleman in question was an ambulance admission to the ED with a three day history of chest pain, shortness of breath and one episode of syncope which brought him to the ED. Over the course of his admission a variety of treatment modalities were used successfully to alleviate the problem. More notable from a nursing perspective was the use of diagnostic tools as an interpretation to guide his care and provide a platform from which a deeper understanding and appreciation of the intricacies the critically ill patient often presents.

CONCLUSION

We found the use of case review very enlightening in understanding the disease process and the decision-making that accompanies this. Whilst our patient was successfully rehabilitated home, we learnt a lot from the experience which has been most beneficial in supporting our understanding of pulmonary embolism.

Mortality risk assessment and the role of thrombolysis in pulmonary embolism

Acute venous thromboembolism remains a frequent disease, with an incidence ranging between 23 and 69 cases per 100,000 population per year. Of these patients, approximately one-third present with clinical symptoms of acute pulmonary embolism (PE) and two-thirds with deep venous thrombosis (DVT). Recent registries and cohort studies suggest that approximately 10% of all patients with acute PE die during the first 1 to 3 months after diagnosis. Overall, 1% of all patients admitted to hospitals die of acute PE, and 10% of all hospital deaths are PE-related. These facts emphasize the need to better implement our knowledge on the pathophysiology of the disease, recognize the determinants of death or major adverse events in the early phase of acute PE, and most importantly, identify those patients who necessitate prompt medical, surgical, or interventional treatment to restore the patency of the pulmonary vasculature.

Treating venous thromboembolism in patients with cancer

Venous thromboembolism (VTE) is a major cause of morbidity and mortality among patients with cancer. Although much is known about the factors that contribute to VTE risk, pre-emptive therapy in high-risk populations is clearly indicated in only a few clinical situations. Low-molecular-weight heparin is still the recommended class of anticoagulants for cancer-associated VTE. Management of VTE in patients with renal failure, hemorrhagic brain metastases, thrombocytopenia and coagulopathy remains challenging with few safe and effective alternatives. Novel oral agents are currently being investigated and may play a role in the future in the treatment of cancer-associated VTE.

Endovascular therapy for acute pulmonary embolism

Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with massive PE (defined by hemodynamic shock) as well as in many patients with submassive PE (defined by right ventricular strain). The best current evidence suggests that modern catheter-directed therapy to achieve rapid central clot debulking should be considered as an early or first-line treatment option for patients with acute massive PE; and emerging evidence suggests a catheter-directed thrombolytic infusion should be considered as adjunctive therapy for many patients with acute submassive PE. This article reviews the current approach to endovascular therapy for acute PE in the context of appropriate diagnosis, risk stratification, and management of acute massive and acute submassive PE.

Massive and submassive pulmonary embolism: experience with an algorithm for catheter-directed mechanical thrombectomy

BACKGROUND

The role of catheter-directed mechanical thrombectomy (CDMT) for the treatment of massive pulmonary embolism (MPE) and submassive pulmonary embolism (SMPE) is not clearly defined. We report our experience with an algorithm for CDMT as a primary treatment in patients with MPE and SMPE.

METHODS

We retrospectively reviewed our experience in treating MPE and SMPE in consecutive patients over a 2-year period (2008-2010). Patients with computed tomography angiography evidence of saddle, main branch, or ≥2 lobar pulmonary emboli in the setting of hypoxia, tachycardia, echocardiographic right heart strain, and/or cardiogenic shock underwent AngioJet CDMT, with or without adjunctive thrombolytic power-pulse spray. Outcomes, including angiographic success, clinical improvement, complications, and survival to discharge, were evaluated.

RESULTS

Fifteen patients (8 men, 7 women; 14 SMPE, 1 SMPE) with a mean age of 59 years (range: 35-90 years) were treated for heart strain (100%), tachycardia (67%), hypoxia (67%), and cardiogenic shock (7%). Ten patients (67%) also received Alteplase power-pulse spray. Resolution of symptoms and improvement in heart strain were achieved in all patients. There were no in-hospital mortalities. Complications occurred in 3 patients (20%), including 2 patients with acute tubular necrosis and 1 patient with an intraoperative cardiac arrest. Average hospitalization was 9 days (range: 4-26 days). All patients were discharged on full anticoagulation. None required supplemental oxygen at discharge.

CONCLUSION

CDMT as primary treatment of MPE and SMPE has a high rate of technical and clinical success in a high-risk patient population. Experience and strict patient selection criteria may improve therapeutic outcomes.

Diagnosis and management of life-threatening pulmonary embolism

Pulmonary embolus (PE) is estimated to cause 200 000 to 300 000 deaths annually. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. The diagnosis of PE in the critically ill is often challenging because the presentation is nonspecific. Computed tomographic pulmonary angiography appears to be the most useful study for diagnosis of PE in the critically ill. For patients with renal insufficiency and contrast allergy, the ventilation perfusion scan provides an alternative. For patients too unstable to travel, echocardiography (especially transesophageal echocardiography) is another option. A positive result on lower extremity Doppler ultrasound can also aid in the decision to treat. The choice of treatment in PE depends on the estimated risk of poor outcome. The presence of hypotension is the most significant predictor of poor outcome and defines those with massive PE. Normotensive patients with evidence of right ventricular (RV) dysfunction, as assessed by echocardiography, comprise the sub-massive category and are at intermediate risk of poor outcomes. Clinically, those with sub-massive PE are difficult to distinguish from those with low-risk PE. Cardiac troponin, brain natriuretic peptide, and computed tomographic pulmonary angiography can raise the suspicion that a patient has sub-massive PE, but the echocardiogram remains the primary means of identifying RV dysfunction. The initial therapy for patients with PE is anticoagulation. Use of vasopressors, inotropes, pulmonary artery (PA) vasodilators and mechanical ventilation can stabilize critically ill patients. The recommended definitive treatment for patients with massive PE is thrombolysis (in addition to anticoagulation). In massive PE, thrombolytics reduce the risk of recurrent PE, cause rapid improvement in hemodynamics, and probably reduce mortality compared with anticoagulation alone. For patients with a contraindication to anticoagulation and thrombolytic therapy, surgical embolectomy and catheter-based therapies are options. Thrombolytic therapy in sub-massive PE results in improved pulmonary perfusion, reduced PA pressures, and a less complicated hospital course. No survival benefit has been documented, however. If one is considering the use of thrombolytic therapy in sub-massive PE, the limited documented benefit must be weighed against the increased risk of life-threatening hemorrhage. The role of surgical embolectomy and catheter-based therapies in this population is unclear. Evidence suggests that sub-massive PE is a heterogeneous group with respect to risk. It is possible that those at highest risk may benefit from thrombolysis, but existing studies do not identify subgroups within the sub-massive category. The role of inferior vena cava (IVC) filters, catheter-based interventions, and surgical embolectomy in life-threatening PE has yet to be completely defined.

Fibrinolysis and thrombectomy for massive pulmonary embolus

Treatment options for massive and submassive pulmonary embolus may include hemodynamic support, fibrinolysis, anticoagulation, and thrombectomy. Selection of the appropriate therapy requires scrutiny of the patient's hemodynamic status, preexisting conditions, risk of complications, and availability of services at the treatment center. This article illustrates a case of successful fibrinolysis and thrombectomy in a woman with massive pulmonary embolus. A discussion of the indications, benefits, and disadvantages of several pharmacologic, radiologic, and surgical interventions considered in pulmonary embolus will follow.

Pulmonary thromboembolic disease. Clinical management of acute and chronic disease

Pulmonary thromboembolism falls between the areas of pulmonology and cardiology, internal medicine and intensive care, radiology and nuclear medicine, and hematology and cardiothoracic surgery. Depending on their clinical background, physicians faced with a patient with a pulmonary thromboembolism may speak different languages and adopt different treatment approaches. Now, however, there is an opportunity to end the Tower of Babel surrounding pulmonary thromboembolism. There is a growing acknowledgement that the key clinical problems in both acute pulmonary embolism and chronic thromboembolic pulmonary hypertension are linked to right ventricular pressure overload and right ventricular failure. As a result, cardiologists and cardiac intensive care specialists are taking an increasing interest in understanding and combating these conditions. The European Society of Cardiology was the first to elaborate comprehensive clinical practice guidelines for pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. The task forces involved in producing these guidelines included radiologists, pulmonologists, hematologists, intensive care physicians and surgeons, which ensured that the final document was universally acceptable. The aim of this article was to provide an overview of the epidemiology, risk factors, diagnosis, treatment, prognosis and prevention of acute pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension, while taking into account European Society of Cardiology guidelines and incorporating new evidence where necessary.

Fibrinolysis for acute pulmonary embolism

Acute pulmonary embolism (PE) presents as a constellation of clinical syndromes with a variety of prognostic implications. Patients with acute PE who have normal systemic arterial blood pressure and no evidence of right ventricular (RV) dysfunction have an excellent prognosis with therapeutic anticoagulation alone. Normotensive acute PE patients with evidence of RV dysfunction are categorized as having submassive PE and comprise a population at intermediate risk for adverse events and early mortality. Patients with massive PE present with syncope, systemic arterial hypotension, cardiogenic shock, or cardiac arrest and have the highest risk for short-term mortality and adverse events. The majority of deaths from acute PE are due to RV pressure overload and subsequent RV failure. The goal of fibrinolysis in acute PE is to rapidly reduce RV afterload and avert impending hemodynamic collapse and death. Although generally considered to be a life-saving intervention in massive PE, fibrinolysis remains controversial for submassive PE. Successful administration of fibrinolytic therapy requires weighing benefit versus risk. Major bleeding, in particular intracranial hemorrhage, is the most feared complication of fibrinolysis. Alternatives to fibrinolysis for acute PE, including surgical embolectomy, catheter-assisted embolectomy, and inferior vena cava (IVC) filter insertion, should be considered when contraindications exist or when patients have failed to respond to an initial trial of fibrinolytic therapy. Patients with massive and submassive PE may be best served by rapid triage to specialized centers with experience in the administration of fibrinolytic therapy and the capacity to offer alternative advanced therapies such as surgical and catheter-assisted embolectomy.

Mortality risk assessment and the role of thrombolysis in pulmonary embolism

Acute venous thromboembolism remains a frequent disease, with an incidence ranging between 23 and 69 cases per 100,000 population per year. Of these patients, approximately one-third present with clinical symptoms of acute pulmonary embolism (PE) and two-thirds with deep venous thrombosis (DVT). Recent registries and cohort studies suggest that approximately 10% of all patients with acute PE die during the first 1 to 3 months after diagnosis. Overall, 1% of all patients admitted to hospitals die of acute PE, and 10% of all hospital deaths are PE-related. These facts emphasize the need to better implement our knowledge on the pathophysiology of the disease, recognize the determinants of death or major adverse events in the early phase of acute PE, and most importantly, identify those patients who necessitate prompt medical, surgical, or interventional treatment to restore the patency of the pulmonary vasculature.

Adjunctive inferior vena cava filter placement for acute pulmonary embolism

Inferior vena cava (IVC) filters are sometimes placed as an adjunct to full anticoagulation in patients with significant pulmonary embolism (PE). We aimed to determine the prevalence of adjunctive IVC filter placement in individuals diagnosed with PE, as well as the effect of adjunctive filter placement on mortality in patients with right heart strain associated with PE. This was a retrospective study of patients with acute PE treated with full anticoagulation admitted to a single academic medical center. Information abstracted from patient charts included presence or absence of right heart strain and of deep-vein thrombosis, and whether or not an IVC filter was placed. The endpoint was in-hospital mortality. Over 2.75 years, we found that 248 patients were diagnosed with acute PE, with an in-hospital mortality rate of 4.4%. The prevalence of adjunctive IVC filter placement was 13.3% (33 of 248), and the prevalence of documented right heart strain was 27.0% (67 of 248). In-hospital mortality was 10.2% in the non-filter-treated group (5 of 49), whereas there were no deaths in the filter-treated group (0 of 18); however, the difference was not statistically significant (P = 0.37). Both the presence of deep-vein thrombosis and of right heart strain increased the likelihood that an adjunctive IVC filter was placed (P < 0.0001 and P < 0.001, respectively). At our institution, patients were treated with IVC filters in addition to anticoagulation in 13.3% of cases of acute PE. Prospective studies or large clinical registries should be conducted to clarify whether this practice improves outcomes.

Asymptomatic Saddle Pulmonary Embolism: Case Report and Literature Review

Saddle pulmonary embolism is defined as a visible thromboembolus straddling the bifurcation of the main pulmonary artery trunk. Patient with saddle pulmonary embolism have a 2-week mortality of 5.8%. 46 years old, hypertensive male, presented with right leg swelling and pain, with no evidence of cardiopulmonary distress. CTA showed a large saddle pulmonary embolus. Doppler ultrasound of right lower extremity, revealed a large filling defect extending from the common femoral vein distally involving the deep femoral vein, femoral vein and popliteal vein on the right.

Diagnosis of saddle embolus on its own is not associated with an unfavorable outcome, therefore should not influence management of PE. Echocardiography done within 48hours in-patient with symptomatic saddle pulmonary embolism reveals mild to moderate right ventricular enlargement in 90% and mild to severe right ventricular dysfunction in 80%. Emerging evidence suggest that primary therapy with thrombolytics and embolectomy, should be used in PE patients who presents with hypotension plus moderate to severe right ventricular dysfunction on echo cardiogram.

Patients with saddle pulmonary embolism can have normal cardiopulmonary reserve; these patients can be managed with conventional treatment for pulmonary embolism in hospital settings, in order to deal with any complications developed during management. Aggressive management should be reserved for patients who are hemodynamically unstable as well as those with echocardiographic evidence of severe right ventricular strain. Physicians should decrease their threshold for suspicion of pulmonary embolism in patients with deep venous thrombosis in the hope of revealing more and more hidden cases of pulmonary embolism.

Critical appraisal on the utility of echocardiography in the management of acute pulmonary embolism

Echocardiography can be used for rapid and accurate risk stratification of patients with pulmonary embolism to appropriately direct the therapeutic strategies for those at high risk. Echocardiography is an ideal risk stratification tool in this regard because of its easy portability to the emergency room or to the bed side. It can be performed at a relatively low cost and at no risk to the patient. Furthermore, echocardiography allows repetitive noninvasive assessment of the cardiovascular and hemodynamic status of the patient and the response to the therapeutic interventions. Right ventricular hypokinesis, persistent pulmonary hypertension, a patent foramen ovale, and a free floating right heart thrombus are echocardiographic markers that identify patients at a higher risk for morbidity and mortality. Such patients warrant special consideration for thrombolysis or embolectomy.

The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll

The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as "Pump, Tank, and Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.

Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques

PURPOSE

Systemic thrombolysis for the treatment of acute pulmonary embolism (PE) carries an estimated 20% risk of major hemorrhage, including a 3%-5% risk of hemorrhagic stroke. The authors used evidence-based methods to evaluate the safety and effectiveness of modern catheter-directed therapy (CDT) as an alternative treatment for massive PE.

MATERIALS AND METHODS

The systematic review was initiated by electronic literature searches (MEDLINE, EMBASE) for studies published from January 1990 through September 2008. Inclusion criteria were applied to select patients with acute massive PE treated with modern CDT. Modern techniques were defined as the use of low-profile devices (< or =10 F), mechanical fragmentation and/or aspiration of emboli including rheolytic thrombectomy, and intraclot thrombolytic injection if a local drug was infused. Relevant non-English language articles were translated into English. Paired reviewers assessed study quality and abstracted data. Meta-analysis was performed by using random effects models to calculate pooled estimates for complications and clinical success rates across studies. Clinical success was defined as stabilization of hemodynamics, resolution of hypoxia, and survival to hospital discharge.

RESULTS

Five hundred ninety-four patients from 35 studies (six prospective, 29 retrospective) met the criteria for inclusion. The pooled clinical success rate from CDT was 86.5% (95% confidence interval [CI]: 82.1%, 90.2%). Pooled risks of minor and major procedural complications were 7.9% (95% CI: 5.0%, 11.3%) and 2.4% (95% CI: 1.9%, 4.3%), respectively. Data on the use of systemic thrombolysis before CDT were available in 571 patients; 546 of those patients (95%) were treated with CDT as the first adjunct to heparin without previous intravenous thrombolysis.

CONCLUSIONS

Modern CDT is a relatively safe and effective treatment for acute massive PE. At experienced centers, CDT should be considered as a first-line treatment for patients with massive PE.

[Update in pulmonary thromboembolic disease]

Pulmonary embolism is part of venous thromboembolism, an important health problem which leads to significant mortality and morbidity with high economic and social burden. A prompt diagnosis and treatment as well as an appropriate prophylaxis are determinant factors in prognosis. This disease continues to demand particular attention namely in the investigation of risk factors, clinical probability algorithms development, diagnostic work-up evaluation, characterization of new therapeutic strategies and thromboprophylaxis recommendations. The present review looks into the current scientific knowledge regarding pulmonary embolism.

Advanced treatment strategies for acute pulmonary embolism, including thrombolysis and embolectomy

The optimal treatment strategy for acute pulmonary embolism relies upon a multidisciplinary team that rapidly assesses available data, performs additional testing if necessary, weighs treatment options, and recommends an appropriate therapeutic plan to the patient and family. Round-the-clock availability is imperative. Centers that specialize in pulmonary embolism management offer a wide range of therapeutic options. Hospitals with more limited facilities should establish pulmonary embolism patient referral and transfer contingency plans that can be activated at a moment's notice. Management options include anticoagulation alone, thrombolysis plus anticoagulation, insertion of an inferior vena caval filter, catheter embolectomy, or surgical embolectomy. The decision-making process requires accurate risk stratification, which is comprised of several crucial components: clinical evaluation that includes history and physical examination, biomarker measurement especially of troponin, as well as assessment of right ventricular size and function based upon chest CT scanning and echocardiography. The 'old school' approach of declaring a benign prognosis based solely upon the presence of normal systemic arterial pressure can delay advanced therapy until after the onset of irreversible cardiogenic shock. We have now formulated a more contemporary, comprehensive, and multifaceted strategy to prognosticate. Our 'new approach' uses advanced treatment strategies in addition to anticoagulation for those pulmonary embolism patients deemed to be at high risk for a poor outcome.

Percutaneous cardiopulmonary support for the treatment of acute pulmonary embolism: summarized review of the literature in Japan including our own experience

BACKGROUND

Acute pulmonary embolism (APE) has high mortality. Some APEs with circulatory collapse or cardiopulmonary arrest have been treated by percutaneous cardiopulmonary support (PCPS) in Japan. But there have been no reports with a large number of series of APE treated with the use of PCPS.

METHODS AND RESULTS

We collected all the reported cases with acute thrombotic pulmonary embolism treated with PCPS before surgical embolectomy or those without surgical embolectomy in Japan, and assessed the effectiveness of PCPS. PCPS was combined with surgical embolectomy in 35% (68 of 193), thrombolytic therapy in 62% (120/193), and catheter therapy in 24% (46/193). The survival rate treated with PCPS was 73% (80% in surgical embolectomy, 71% in thrombolytic therapy, and 76% in catheter therapy). Logistic regression analysis showed that the mortality rate was elevated in cases with cardiopulmonary arrest (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.52-7.67; p-value, 0.003) but not by surgical embolectomy (OR, 0.99; 95% CI, 0.39-2.53; p-value, 0.98), catheter therapy (OR, 0.71; 95% CI, 0.30-1.72; p-value, 0.45), and thrombolysis (OR, 1.60; 95% CI, 0.64-3.99; p-value, 0.31) as regards to the concomitant therapies with PCPS.

CONCLUSION

PCPS might improve the survival rate in APE patients with circulatory collapse or cardiopulmonary arrest, but there was no differences in outcome among cases treated by surgical embolectomy, catheter therapy, and thrombolysis as the concomitant therapies.

A porcine model of massive, totally occlusive, pulmonary embolism

BACKGROUND

A reliable, animal model of massive, totally occlusive, pulmonary embolism (PE) is lacking.

OBJECTIVES

To design an animal model of totally occlusive PE and to challenge the model by a plasminogen activator.

METHODS

In eight anaesthetized pigs (approximately 90 kg) a massive preformed autologous thrombus was injected into the caval vein. One animal was autopsied to assess the extent of injected clot, whereas in the other animals extracorporeal life support (ECLS) was initiated and continued for three hours. These animals received 100 mg rt-PA. Blood gases, coagulation tests, creatine kinase (CK), lactate dehydrogenase (LDH), end-tidal CO2, systemic and pulmonary artery blood pressures and flow were registered.

RESULTS

All animals went into circulatory arrest within 2 minutes after injection of the thrombus. In the animal where ECLS was not started, autopsy relieved a totally occlusive embolus of the pulmonary artery. The ECLS maintained a systemic blood flow of 6-8 L/min with adequate oxygenation and CO2-removal. However, lactate increased and base-excess became negative. Ddimer increased, fibrinogen decreased, and CK and LDH increased. All seven animals were weaned from ECLS. Despite the rt-PA treatment, the animals had at that time low end tidal CO2/PaCO2 ratio and increased mean pulmonary arterial pressure, suggesting a significant amount of embolic material remaining in the pulmonary artery.

CONCLUSION

This model of massive, totally occlusive, pulmonary embolism mimics well fatal PE seen in the clinic, and has the potential for use in testing of new therapeutic interventions.

Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.