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Elheet AA, Elhadidy AF, Farrag MH, Mahmoud MA, Ibrahim AA, AlAbdali AM, Kazim H, Elganainy MN. Ultrasound-Facilitated, Catheter-Directed Thrombolysis for Acute Pulmonary Embolism. Cureus 2024; 16:e57345. [PMID: 38690498 PMCID: PMC11060753 DOI: 10.7759/cureus.57345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Acute pulmonary embolism (APE) poses a significant risk to patient health, with treatment options varying in efficacy and safety. Ultrasound-facilitated catheter-directed thrombolysis (USCDT) has emerged as a potential alternative to conventional catheter-directed thrombolysis (CDT) for patients with intermediate to high-risk APE. This study aimed to compare the efficacy and safety of USCDT versus conventional CDT in patients with intermediate to high-risk APE. METHODS This observational retrospective study was conducted at the Armed Forces Hospital, Al-Hada, Taif, the Kingdom of Saudi Arabia (KSA), on 135 patients diagnosed with APE and treated with either USCDT or CDT (58 underwent CDT, while 77 underwent USCDT). The primary efficacy outcome was the change in the right ventricle to the left ventricle (RV/LV) diameter ratio. Secondary outcomes included changes in pulmonary artery systolic pressure and the Miller angiographic obstruction index score. Safety outcomes focused on major bleeding events. RESULTS Both USCDT and CDT significantly reduced RV/LV diameter ratio (from 1.35 ± 0.14 to 1.05 ± 0.17, P < 0.001) and systolic pulmonary artery pressure (SPAP) (from 55 ± 7 mmHg to 38 ± 7 mmHg, P < 0.001) at 48- and 12-hours post-procedure, respectively, with no significant differences between treatments. However, USCDT was associated with a significantly lower rate of major bleeding events compared to CDT (0% vs. 3.4%, P = 0.008). Multivariate logistic regression analysis revealed that USCDT was associated with a 71.9% risk reduction of bleeding (OR = 0.281, 95% CI = 0.126 - 0.627, P = 0.002). CONCLUSIONS USCDT is a safe and effective alternative to CDT for the treatment of intermediate to high-risk APE, as it significantly reduces the risk of major bleeding.
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Affiliation(s)
- Ahmed A Elheet
- Cardiovascular Disease, Mahalla Cardiac Center, Tanta, EGY
- Cardiovascular Disease, Al Hada Armed Forces Hospital, Taif, SAU
| | | | - Mohamad H Farrag
- Cardiovascular Medicine, Al Hada Armed Force Hospital, Taif, SAU
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Mohamad T, Kanaan E, Ogieuhi IJ, Mannaparambil AS, Ray R, Al-Nazer LWM, Ahmed HM, Hussain M, Kumar N, Kumari K, Nadeem M, Kumari S, Varrassi G. Thrombolysis vs Anticoagulation: Unveiling the Trade-Offs in Massive Pulmonary Embolism. Cureus 2024; 16:e52675. [PMID: 38380194 PMCID: PMC10877223 DOI: 10.7759/cureus.52675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
Massive pulmonary embolism (MPE) is a severe form of venous thromboembolism (VTE) wherein enormous blood clots block the pulmonary arteries, resulting in substantial illness and death. Even with the progress made in diagnostic methods and treatments, the most effective approach for managing MPE is still a topic of considerable discussion. This study examines the delicate equilibrium between thrombolysis and anticoagulation in managing the problematic clinical situation posed by MPE, elucidating the compromises linked to each strategy. The genesis of MPE lies in the pathophysiology of VTE, when blood clots that originate from deep veins in the lower legs or pelvis move to the pulmonary vasculature, leading to an abrupt blockage. This obstruction leads to a series of hemodynamic alterations, such as elevated pulmonary vascular resistance, strain on the right ventricle, and compromised cardiac output, finally resulting in cardiovascular collapse. The seriousness of MPE is commonly categorized according to hemodynamic stability, with significant cases presenting immediate risks to patient survival. Traditionally, heparin has been the primary approach to managing MPE to prevent the spread of blood clots and their movement to other parts of the body. Nevertheless, there have been ongoing discussions regarding the effectiveness of thrombolysis, which entails the immediate delivery of fibrinolytic drugs to remove the blood clot. The use of thrombolysis in managing MPE is being reconsidered because of concerns over bleeding complications and long-term results despite its capacity to resolve the blocking clot quickly. This review rigorously analyzes the current body of evidence, exploring the intricacies of thrombolysis and anticoagulation in MPE. The focus is on evaluating the risk-benefit balance of each treatment option, considering aspects such as the patient's other medical conditions, hemodynamic stability, and potential long-term consequences. This review aims to clarify the complexities of the thrombolysis versus anticoagulation dilemma. It seeks to provide clinicians, researchers, and policymakers with a thorough understanding of the trade-offs in managing MPE. The goal is to facilitate informed decision-making and enhance patient outcomes.
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Affiliation(s)
- Tamam Mohamad
- Cardiovascular Medicine, Wayne State University, Detroit, USA
| | - Eyas Kanaan
- Internal Medicine, Corewell Health, Grand Rapids, USA
| | - Ikponmwosa J Ogieuhi
- Physiology, University of Benin, Benin City, NGA
- General Medicine, Siberian State Medical University, Tomsk, RUS
| | | | - Rubela Ray
- Internal Medicine, Bankura Sammilani Medical College and Hospital, Bankura, IND
| | | | | | | | | | - Komal Kumari
- Medicine, NMC Royal Family Medical Centre, Abu Dhabi, ARE
| | | | - Sanvi Kumari
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Söffker G, Janssens U, Kluge S. [Ten key messages of the S2k guideline on diagnostics and therapy of venous thrombosis and pulmonary embolism]. Med Klin Intensivmed Notfmed 2023:10.1007/s00063-023-01018-7. [PMID: 37099148 DOI: 10.1007/s00063-023-01018-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Affiliation(s)
- Gerold Söffker
- Klinik für Intensivmedizin., Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, Deutschland.
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital Eschweiler, Eschweiler, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin., Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, Deutschland
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Russo D, Massaro G, Sangiorgi GM. Successful percutaneous catheter-directed treatment of high-risk pulmonary embolism: a case report. AME Case Rep 2023; 7:5. [PMID: 36817704 PMCID: PMC9929660 DOI: 10.21037/acr-22-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023]
Abstract
Background Pulmonary embolism (PE) is an acute cardiovascular syndrome characterized by high incidence and mortality. The therapy of this condition is based on anticoagulation and hemodynamic support, but in case of high-risk mortality, the European Society of Cardiology (ESC) guidelines recommend systemic thrombolytic therapy and surgical embolectomy if thrombolysis is contraindicated or has failed; nowadays several percutaneous catheter-directed treatments for local thrombolysis or mechanical embolectomy are available, but they have IIa class of recommendation, because of lack of robust scientific evidence favoring their use. Case Description We described a case of high-risk PE treated with a novel percutaneous system for mechanical embolectomy, which consists of a large aspiration catheter that was advanced in the pulmonary artery, capturing and removing a vast thrombus, of 15 centimeters in length. This therapeutic strategy avoided the risk of hemorrhagic complications related to systemic thrombolysis, exiting in the achievement of fast patient hemodynamic stabilization and symptoms resolution, without complications. Computed tomography (CT) pulmonary angiography after 10 days from the intervention revealed the complete resolution of pulmonary artery filling defects, and the patient was discharged asymptomatic. Conclusions Percutaneous catheter-directed treatments represent an effective alternative therapy for PE, but further studies are needed to demonstrate safety and superiority over the actually recommended therapy.
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Affiliation(s)
- Debora Russo
- Department of Cardiovascular Disease, University of Rome Tor Vergata, Rome, Italy
| | - Gianluca Massaro
- Department of Cardiovascular Disease, University of Rome Tor Vergata, Rome, Italy
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Hylek EM. Catheter-Directed Treatment of Submassive Pulmonary Embolism-A Cautious Step Closer? JAMA Cardiol 2022; 7:1197-1198. [PMID: 36260318 DOI: 10.1001/jamacardio.2022.3603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Elaine M Hylek
- Boston University School of Medicine, Boston, Massachusetts
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