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Percutaneous thrombectomy in patients with intermediate- and high-risk pulmonary embolism and contraindications to thrombolytics: a systematic review and meta-analysis. J Thromb Thrombolysis 2023; 55:228-242. [PMID: 36536090 PMCID: PMC9762655 DOI: 10.1007/s11239-022-02750-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
Catheter-directed interventions have slowly been gaining ground in the treatment of pulmonary embolism (PE), especially in patients with increased risk of bleeding. The goal of this study is to summarize the evidence for the efficacy and safety of percutaneous thrombectomy (PT) in patients with contraindications to systemic and local thrombolysis. We performed a systematic review and meta-analysis using MEDLINE, Cochrane, Scopus and the Web of Science databases for studies from inception to March 2022. We included patients with intermediate- and high-risk PE with contraindications to thrombolysis; patients who received systematic or local thrombolysis were excluded. Primary endpoint was in-hospital and 30-day mortality, with secondary outcomes based on hemodynamic and radiographic changes. Major bleeding events were assessed as a safety endpoint. Seventeen studies enrolled 455 patients, with a mean age of 58.6 years and encompassing 50.4% females. In-hospital and 30-day mortality rates were 4% (95% CI 3-6%) and 5% (95% CI 3-9%) for all-comers, respectively. We found a post-procedural reduction in systolic and mean pulmonary arterial pressures by 15.4 mmHg (95% CI 7-23.7) and 10.3 mmHg (95% CI 3.1-17.5) respectively. The RV/LV ratio and Miller Index were reduced by 0.42 (95% CI 0.38-46) and 7.8 (95% CI 5.2-10.5). Major bleeding events occurred in 4% (95% CI 3-6%). This is the first meta-analysis to report pooled outcomes on PT in intermediate- and high-risk PE patients without the use of systemic or local thrombolytics. The overall mortality rate is comparable to other contemporary treatments, and is an important modality particularly in those with contraindications for adjunctive thrombolytic therapy. Further studies are needed to understand the interplay of anticoagulation with PT and catheter-directed thrombolysis.
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Carroll BJ, Larnard EA, Pinto DS, Giri J, Secemsky EA. Percutaneous Management of High-Risk Pulmonary Embolism. Circ Cardiovasc Interv 2023; 16:e012166. [PMID: 36744463 DOI: 10.1161/circinterventions.122.012166] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/04/2023] [Indexed: 02/07/2023]
Abstract
Acute pulmonary embolism (PE) leads to an abrupt increase in pulmonary vascular resistance and right ventricular afterload, and when significant enough, can result in hemodynamic instability. High-risk PE is a dire cardiovascular emergency and portends a poor prognosis. Traditional therapeutic options to rapidly reduce thrombus burden like systemic thrombolysis and surgical pulmonary endarterectomy have limitations, both with regards to appropriate candidates and efficacy, and have limited data demonstrating their benefit in high-risk PE. There are growing percutaneous treatment options for acute PE that include both localized thrombolysis and mechanical embolectomy. Data for such therapies with high-risk PE are currently limited. However, given the limitations, there is an opportunity to improve outcomes, with percutaneous treatments options offering new mechanisms for clot reduction with a possible improved safety profile compared with systemic thrombolysis. Additionally, mechanical circulatory support options allow for complementary treatment for patients with persistent instability, allowing for a bridge to more definitive treatment options. As more data develop, a shift toward a percutaneous approach with mechanical circulatory support may become a preferred option for the management of high-risk PE at tertiary care centers.
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Affiliation(s)
- Brett J Carroll
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Emily A Larnard
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Duane S Pinto
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jay Giri
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia (E.A.S.)
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Han X, Zhang Q, Xia F, Zhang Y, Wang W. Exploration of risk factors for hemoglobinuria and acute kidney injury following iliofemoral venous mechanical thrombectomy. J Interv Med 2023; 6:24-28. [PMID: 37180365 PMCID: PMC10167515 DOI: 10.1016/j.jimed.2022.10.005] [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: 05/29/2022] [Revised: 10/15/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022] Open
Abstract
Objective To evaluate the risk factors for hemoglobinuria and acute kidney injury (AKI) after percutaneous mechanical thrombectomy (MT) with or without catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (IFDVT). Methods Patients with IFDVT who had MT with the AngioJet catheter (group A), MT plus CDT (group B), or CDT alone (group C) from January 2016 to March 2020 were retrospectively evaluated. Hemoglobinuria was monitored throughout the treatment course, and postoperative AKI was assessed by comparing the preoperative (baseline) and postoperative serum creatinine (sCr) levels from the electronic medical records of all patients. AKI was defined as an elevation in the sCr level exceeding 26.5 μmol/L within 72 h after the operation according to the Kidney Disease Improving Global Outcomes criteria. Results A total of 493 consecutive patients with IFDVT were reviewed, of which 382 (mean age, 56 ± 11 years; 41% of them were females; 97 in group A, 128 in group B, and 157 in group C) were finally analyzed. Macroscopic hemoglobinuria was evident in 44.89% of the patients of the MT groups (101/225, 39 in group A, and 62 in group B), with no significant difference between the groups (P = 0.219), but not in the patients in group C. None of the patients developed AKI (mean sCr difference -2.76 ± 13.80 μmol/L, range = -80.20 to 20.60 μmol/L) within 72 h after surgery. Conclusions Rheolytic MT is an independent risk factor for hemoglobinuria. A proper aspiration strategy, hydration, and alkalization following thrombectomy are particularly favorable for preventing AKI.
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Affiliation(s)
- Xinqiang Han
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Qingqing Zhang
- Department of Cerebrovascular, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Fengfei Xia
- Department of Interventional Medicine and Vascular, Binzhou Peoples Hospital, Binzhou, 256600, Shandong, China
| | - Yongzhen Zhang
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
| | - Wenming Wang
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, Binzhou, 256603, Shandong, China
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Tohme S, Newman JS, Gasparis C, Manetta F. Massive Embolism: Knife versus PCI. Int J Angiol 2022; 31:179-187. [PMID: 36157101 PMCID: PMC9507597 DOI: 10.1055/s-0042-1755573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Pulmonary embolism is the third most common cardiovascular syndrome with an estimated up to 25% of patients presenting with sudden death. For those who survive, a mainstay of management for patients with hemodynamic stability is anticoagulation; however, recommendations and options are rapidly changing for patients with submassive or massive pulmonary embolism with hemodynamic instability. Catheter-based and surgical approaches offer efficacious management options for unstable patients or patients with contraindications to anticoagulation; however, both approaches have inherent benefits and risk. This article seeks to offer a brief review on the recommendations and options for management of pulmonary embolism from both surgical and catheter-based perspectives.
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Affiliation(s)
- Scarlett Tohme
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Joshua S. Newman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Christopher Gasparis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Angiojet System Used in the Treatment of Submassive Pulmonary Embolism: A Case Report of Two Patients. Case Rep Vasc Med 2022; 2022:6867338. [PMID: 36051456 PMCID: PMC9427312 DOI: 10.1155/2022/6867338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Massive or submassive pulmonary embolism (PE) carries a high mortality. Percutaneous mechanical thrombectomy using the Angiojet system is accepted for the treatment of PE. Here, we reported two submassive PE cases who were treated with the Angiojet system successfully, to provide some advice for the therapy of submassive PE. Method Two patients with suffocation were admitted to our hospital. One patient was accompanied by lower blood pressure (20% lower than basal blood pressure) and higher pulmonary artery pressure (89 mmHg); the other patient had larger right ventricular transverse diameter (46 mm), decreased left ventricular end diastolic anteroposterior diameter (34 mm), and higher heartbeats (107 heartbeats per minute). Pulmonary artery computed tomography angiography showed bilateral pulmonary embolism. Result The Angiojet system with a high-pressure jet spray pattern (urokinase 25 wiu + sodium chloride injection 50 ml) was used. Intravascular thrombolysis by urokinase (100 wiu/day for 1 day) was done after being back in the ward. And low molecular weight heparin was used in hospitalization, and rivaroxaban was used after discharge. Both patients were treated successfully. However, the level of platelet was significantly lower in one patient after Angiojet system usage and recovered to the preoperative level the next day. Another patient suffered from bradyarrhythmias during the usage of Angiojet, and bradyarrhythmias disappeared when the Angiojet system stopped. Pulmonary embolism was cured after 3 months in both patients. Conclusion Angiojet could be a simple, safe, and well-tolerated treatment for massive or submassive PE. And hematocrit, platelet, kidney function, and heart rhythm should be monitored during perioperation.
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Jo EA, Choi KW, Han A, Ahn S, Min S, Jae H, Lee M, Min SK. Percutaneous Mechanical Thrombectomy of Submassive Pulmonary Embolism and Extensive Deep Venous Thrombosis for Early Thrombus Removal. Vasc Specialist Int 2021; 37:47. [PMID: 35008066 PMCID: PMC8752335 DOI: 10.5758/vsi.210061] [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: 08/10/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 11/20/2022] Open
Abstract
Traditional treatment with anticoagulation in nonfatal submassive pulmonary embolism can result in serious sequelae of chronic thromboembolic pulmonary hypertension or poor exercise tolerance, and functional impairment. To prevent long-term complications in previously healthy young patients, other treatment options to actively resolve existing thrombi should be considered. Despite recommendations for use in only severe clinical presentations, endovascular interventional techniques could serve as suitable treatment options for such patients. Here we report the case of a previously healthy 23-year-old female with submassive pulmonary embolism and extensive deep vein thrombosis in the inferior vena cava down to the right popliteal vein. The patient was initially treated with catheter-directed thrombolysis. However, she continued to show extensive venous thrombosis and pulmonary embolism. Percutaneous thrombectomy and aspiration using an AngioJet successfully removed the main pulmonary artery embolism and venous thrombus. The patient's recovery was uneventful, and 3-month follow-up showed no signs of recurrence or discomfort.
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Affiliation(s)
- Eun-Ah Jo
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Woo Choi
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ahram Han
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sanghyun Ahn
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sangil Min
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hwanjun Jae
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Myungsu Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Akbal ÖY, Keskin B, Tokgöz HC, Hakgör A, Karagöz A, Tanyeri S, Kültürsay B, Külahçıoğlu Ş, Bayram Z, Efe S, Erkılınç A, Tanboğa İH, Doğan C, Akbulut M, Özdemir N, Kaymaz C. A seven-year single-center experience on AngioJet rheolytic thrombectomy in patients with pulmonary embolism at high risk and intermediate-high risk. Anatol J Cardiol 2021; 25:902-911. [PMID: 34866585 DOI: 10.5152/anatoljcardiol.2021.28303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIM Angiojet Rheolytic thrombectomy (ART) has been utilized as a catheter-based treatment in acute pulmonary embolism (PE). In this study based on our seven-year experience on ART in patients with PE, we evaluated efficacy and safety outcomes of ART. METHODS Our study is based on retrospective evaluation of 56 patients with high- and intermediate-high-risk PE, age (62 years; interquartile-range (IQR): 50-73) who underwent ART. RESULTS High- and intermediate-high-risk were noted in 21.4 % and in 78.6 % of patients, respectively. ART duration was 304(IQR: 246-468) seconds. Measures of obstruction, right to left ventricle diameter ratio (RV/LV ratio), right to left atrial diameter ratio and pulmonary arterial pressures were improved (p<0.001 for all). During hospital stay, acute renal failure, major and minor bleeding, and mortality rates were 37.5%, 7.1%, 12.5%, and 8.9%, respectively. Aging related to post-procedural nephropathy while high-risk status was associated with in-hospital mortality (p=0.006) and long-term mortality. CONCLUSIONS The ART resulted in significant and clinically relevant improvements in the pulmonary arterial thrombotic burden, RV strain and hemodynamics in patients with PE at high- and intermediate-high-risk. Aging increased the risk of post-procedural nephropathy whereas baseline high-risk status predicted in-hospital and long-term mortality.
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Affiliation(s)
- Özgur Yaşar Akbal
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Berhan Keskin
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Hacer Ceren Tokgöz
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Aykun Hakgör
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Ali Karagöz
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Seda Tanyeri
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Barkın Kültürsay
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Şeyhmus Külahçıoğlu
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Zübeyde Bayram
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Süleyman Efe
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Atakan Erkılınç
- Department of Anesthesiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - İbrahim Halil Tanboğa
- Department of Cardiology, Faculty of Medicine, Nişantaşı University; İstanbul-Turkey
| | - Cem Doğan
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Mehmet Akbulut
- Department of Cardiology, Faculty of Medicine, Fırat University; Elazığ-Turkey
| | - Nihal Özdemir
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
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Li K, Cui M, Zhang K, Liang K, Liu H, Zhai S. Treatment of acute pulmonary embolism using rheolytic thrombectomy. EUROINTERVENTION 2021; 17:e158-e166. [PMID: 32863245 PMCID: PMC9725013 DOI: 10.4244/eij-d-20-00259] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The AngioJet rheolytic thrombectomy (ART) system can quickly fragment and aspirate thrombi according to Bernoulli's principle. AIMS This retrospective study aimed to evaluate the therapeutic effects of the ART system in treating severe acute pulmonary embolism (APE), including high-risk pulmonary embolism (HR-PE) and intermediate-high-risk pulmonary embolism (IHR-PE). METHODS Forty-four APE patients (21 HR-PE and 23 IHR-PE) were enrolled and underwent pulmonary ART using the 6 Fr Solent Omni AngioJet device. Nineteen patients were diagnosed with APE and lower extremity deep venous thrombosis (LEDVT), and underwent thrombectomy of APE and LEDVT simultaneously using ART. All patients also received local thrombolysis with urokinase. RESULTS The results showed that the mean length of stay in intensive care units was 2.4±1.9 days. Significant improvements in clinical, haemodynamic and angiographic parameters were observed in both groups; the improvements in shock index, PaO2, and angiographic parameters were more obvious in the IHR-PE group. Six of the 44 patients died in hospital. During the follow-up, 35 of 38 patients were functioning well and no recurrence of APE was observed. CONCLUSIONS Pulmonary ART plus local thrombolysis of the pulmonary artery for HR-PE or IHR-PE is feasible and appears to be safe. Further studies are warranted to investigate comparative efficacy compared to existing treatments.
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Affiliation(s)
- Kun Li
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Mingzhe Cui
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Kewei Zhang
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Kai Liang
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Heng Liu
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Shuiting Zhai
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, 7 Weiwu Road, Zhengzhou, Henan, 450003, China
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Einarsson F, Sandström C, Svennerholm K, Oras J, Rylander C. Outcomes of catheter-directed interventions in high-risk pulmonary embolism-a retrospective analysis. Acta Anaesthesiol Scand 2021; 65:499-506. [PMID: 33245785 PMCID: PMC7986106 DOI: 10.1111/aas.13753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND First-line treatment of high-risk pulmonary embolism with persistent hypotension and/or signs of shock is intravenous thrombolysis. However, if thrombolysis is contraindicated due to risk of serious bleeding, or if it yields insufficient effect, surgical thrombectomy or catheter-directed intervention (CDI) plus anticoagulation is recommended. The aim of this study was to assess the outcomes of the CDI modality introduced in a tertiary referral centre in 2013. METHODS Retrospective comparison between patients treated with CDI plus anticoagulation (n = 22) and patients treated with anticoagulation only (n = 23) as used before the CDI technique was available. The main outcomes of interest were 90-day survival and reduction of right to left ventricle diameter (RV/LV) ratio, using the Fischer's exact test and a mixed model, respectively, for statistical analysis. RESULTS Ninety-day survival was 59% after CDI and 61% after anticoagulation only; P = .903. The rate of RV/LV ratio reduction was 0.4 units higher per 24 hours in the CDI group (median 2.1 pre-treatment), than in the anticoagulation only group (median 1.3 pre-treatment); P = .007. CONCLUSION In patients with high-risk pulmonary embolism, 90-day survival was similar after treatment with CDI plus anticoagulation compared to anticoagulation only. The mean reduction in RV/LV ratio was larger in the CDI group. Our results support the use of CDI in selected patients, respecting the limitations and potential side effects of each technical device used.
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Affiliation(s)
- Freyr Einarsson
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Charlotte Sandström
- Department of RadiologyInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Jonatan Oras
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care MedicineInstitute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
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Acute Distress Respiratory Syndrome and Cardiac Shock after AngioJet Thrombectomy for Acute Occlusion of an Aortic Endograft. Ann Vasc Surg 2020; 70:569.e11-569.e14. [PMID: 32927032 DOI: 10.1016/j.avsg.2020.08.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 11/20/2022]
Abstract
Partial thrombosis or total occlusion of aortic or limb graft are possible complications after endovascular aneurysm repair. Different strategies for therapeutic management are available; these include open surgical techniques or endovascular treatments. The choice of the treatment depends on the patient's clinical conditions and on the timing of the thrombosis. Bypass still remains the first choice in case of chronic occlusion but in the last 10 years, the use of percutaneous mechanical/rheolytic thrombectomy systems is increasing. These devices can be used in case of acute or subacute onset of native arterial and venous thrombosis or embolism and in case of graft occlusion. AngioJet is a percutaneous rheolytic mechanical thrombectomy system. Through a pressurized saline solution jet, a low-pressure zone is made up and the thrombus is fragmented and aspirated by the device. Different transient adverse effects caused by lysis of the thrombus are described such as hemoglobinuria but in some cases the release of high doses of the thrombus degradation products such as heme and adenosine diphosphate can lead to fatal consequences for the patient. We reported a case of an acute onset of acute distress respiratory syndrome, pulmonary edema, cardiac shock, and renal failure following AngioJet thrombectomy in an 81-year-old man with an acute occlusion of an aortic endograft.
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11
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Meta-Analysis of the Usefulness of Inferior Vena Cava Filters in Massive and Submassive Pulmonary Embolism. Am J Cardiol 2020; 128:54-59. [PMID: 32650924 DOI: 10.1016/j.amjcard.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/24/2020] [Accepted: 05/01/2020] [Indexed: 02/06/2023]
Abstract
To conduct a systematic review and meta-analysis evaluating the safety and effectiveness of inferior vena cava filter (IVCF) placement in the setting of massive and submassive pulmonary embolism (PE), Pubmed and Cochrane Library were queried to identify all clinical studies evaluating IVCF placement in patients with massive and submassive PE from database establishment to December 2019. The rate of recurrent PE, PE-related mortality, adverse events, IVCF type, additional treatment intervention, DVT status, and follow-up length were retrieved. Recurrent PE, mortality, and complication rates were pooled. Meta-analysis was performed to compare mortality rates between groups with and without IVCF placement. Subgroup analysis was performed based on whether catheter-directed therapy was used for PE intervention. Fifteen observational studies with a total of 232 patients who received IVCF for submassive or massive PE were included. The pooled overall recurrent symptomatic PE and mortality rates were 1.4% and 5.5%, respectively. A lower mortality rate among patients with IVCF was observed than those without (6.8% vs 26.3%; odds ratio [OR] 0.275 [95% confidence interval] 0.090 to 0.839], I2 = 30.6%, p = 0.023). Patients who received concurrent catheter-directed therapy demonstrated a lower recurrent PE (0% vs 2.8%) and mortality rate (3.4% vs 7.8%) than those who did not. The cumulative IVCF-related complication rate was 0.63%. In conclusion, based on a limited amount of low-quality evidence, IVCF placement is associated with low recurrent PE and PE-related mortality rates among patients with massive and submassive PE, suggestive of a potential clinical benefit in this scenario. Prospectively designed studies are warranted to confirm these findings.
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12
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Villalba L, Nguyen T, Feitosa RL, Gunanayagam P, Anning N, Dwight K. Single-session catheter-directed lysis using adjunctive power-pulse spray with AngioJet for the treatment of acute massive and submassive pulmonary embolism. J Vasc Surg 2019; 70:1920-1926. [PMID: 31147112 DOI: 10.1016/j.jvs.2019.03.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/04/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE An alternative single-session catheter-directed thrombolysis (CDT) method using adjunctive power-pulse spray (PPS) technique (with the AngioJet system; Boston Scientific, Fremont, Calif) was investigated to evaluate its safety and effectiveness in the treatment of acute massive and submassive high-risk pulmonary embolism (PE). METHODS Between May 2016 and July 2018, patients diagnosed with extensive massive or submassive PE who triggered intensive care unit involvement and were considered for escalation of treatment were offered CDT with adjunctive PPS technique, provided they met the clinical inclusion criteria. Clinical success was defined as stabilization of hemodynamic parameters, resolution of hypoxia, and survival to discharge. In addition, reversal of right ventricular (RV) failure and pulmonary artery hypertension was evaluated after 24 to 48 hours using echocardiography. After 4 weeks, echocardiography was repeated to check for reversal of RV failure and pulmonary artery hypertension. In addition, computed tomography pulmonary angiography was performed to check for residual thrombus. Functional capacity was also re-evaluated at the follow-up consultation. RESULTS During the study period, 575 inpatients were diagnosed with PE at The Wollongong Hospital. Of these patients, 32 (5.6%) were referred for escalation of treatment, met the inclusion criteria, and received treatment with the CDT and PPS technique. These patients were classified as having massive (23 [71.9%]) or submassive (9 [28.1%]) PE. Technical success was achieved in all 32 patients, and 31 patients survived to discharge (96.9%). There were no major or minor adverse events and no procedure-related complications. Improvement of RV strain and pulmonary hypertension was achieved in all survivors within 48 hours of the intervention. Furthermore, all echocardiograms completed at 4 weeks after discharge were reported normal. Results from computed tomography pulmonary angiography 4 weeks after discharge demonstrated complete resolution of thrombus in 79.3% of patients, and the remaining 20.7% had only minor residual thrombus reported. In addition, 82.8% of patients reported a return to premorbid exercise tolerance by the time of postoperative consultation with the treating physician (mean follow-up, 6.7 weeks). CONCLUSIONS This initial series indicates that single-session CDT with adjunctive PPS technique using the AngioJet system is safe and effective in treating massive and submassive acute PE. It appears to offer several potential advantages compared with current options, allowing safer and faster thrombus resolution. Multicenter prospective trials are required to validate these findings.
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Affiliation(s)
- Laurencia Villalba
- Department of Vascular Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia; Vascular Care Centre, Wollongong, New South Wales, Australia; University of Wollongong, Graduate School of Medicine, Wollongong, New South Wales, Australia.
| | - Tam Nguyen
- Department of Vascular Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia; Vascular Care Centre, Wollongong, New South Wales, Australia
| | - Rui L Feitosa
- Department of Vascular Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Prashanth Gunanayagam
- Department of Vascular Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Naomi Anning
- Department of Vascular Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Kate Dwight
- Vascular Care Centre, Wollongong, New South Wales, Australia
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A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism. JACC Cardiovasc Interv 2019; 12:859-869. [DOI: 10.1016/j.jcin.2018.12.022] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/03/2018] [Accepted: 12/18/2018] [Indexed: 12/25/2022]
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14
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[New aspects of thrombolysis and thrombectomy in pulmonary embolism]. Herz 2019; 44:324-329. [PMID: 30941473 DOI: 10.1007/s00059-019-4801-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pulmonary embolism is a potentially life-threatening disease, which can present with varying severity. Based on an emergency risk stratification, the initial treatment strategy should be chosen without delay. While patients with a low mortality risk can be treated in an outpatient setting, patients at high risk should proceed to immediate recanalization by thrombolysis or thrombectomy. Systemic thrombolysis is the first line therapy in the absence of contraindications. The dosing (low versus full dose) and application (systemic versus local via a catheter) of alteplase, the most frequently used agent, is the subject of a number of current studies with the goal to reduce the risk of bleeding. In the case of contraindications for systemic thrombolysis surgical or alternatively, interventional thrombectomy should be performed. This article discusses these procedures in the light of the currently available literature.
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15
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Surgical pulmonary embolectomy and catheter-based therapies for acute pulmonary embolism: A contemporary systematic review. J Thorac Cardiovasc Surg 2018; 156:2155-2167. [DOI: 10.1016/j.jtcvs.2018.05.085] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 12/26/2022]
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16
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Moriarty JM, Edwards M, Plotnik AN. Intervention in Massive Pulmonary Embolus: Catheter Thrombectomy/Thromboaspiration versus Systemic Lysis versus Surgical Thrombectomy. Semin Intervent Radiol 2018; 35:108-115. [PMID: 29872246 DOI: 10.1055/s-0038-1642039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Massive pulmonary embolus (PE), defined as hemodynamic shock from acute PE, is a life-threatening condition. Deaths from massive PE, especially when unsuspected, occur within minutes to hours of onset and as such prompt intervention can be lifesaving. Acute massive PE patients have traditionally been candidates for treatment with intravenous systemic thrombolysis to improve pulmonary artery pressure, arteriovenous oxygenation, and pulmonary perfusion in an effort to reduce mortality. However, patients with contraindications to systemic thrombolysis or those who have failed thrombolysis may benefit from other techniques including endovascular and surgical embolectomy. This article will review the current medical management as well as catheter-directed therapies and surgical embolectomy in the treatment of patients with massive PE.
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Affiliation(s)
- John M Moriarty
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Martin Edwards
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Adam N Plotnik
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
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17
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Treatment of high- and intermediate-risk pulmonary embolism using the AngioJet percutaneous mechanical thrombectomy system in patients with contraindications for thrombolytic treatment - a pilot study. Wideochir Inne Tech Maloinwazyjne 2018; 13:233-242. [PMID: 30002757 PMCID: PMC6041588 DOI: 10.5114/wiitm.2018.75848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/02/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Intravenous thrombolysis is the treatment of choice in patients presenting with high- and intermediate-risk pulmonary embolism. The role of percutaneous mechanical pulmonary thrombectomy (PMPT) is not fully established, although selected patients can be managed with this method. Aim This open-label single-centre prospective pilot study was aimed at assessing the feasibility of PMPT for the treatment of severe pulmonary embolism in a Polish hospital. We also evaluated the safety and efficacy of such management. Material and methods We managed 7 patients, aged 52.7 ±16.6 years, presenting with high- and intermediate-risk pulmonary embolism (4 patients with class 5 and one patient with class 4 of the Pulmonary Embolism Severity Index), with occlusion of at least 2 lobar arteries and contraindications for thrombolysis. Percutaneous mechanical pulmonary thrombectomy was performed using the AngioJet system. Results It was possible to introduce the thrombectomy system to the pulmonary arteries in all patients. The procedure was successful in 6 patients (technical success rate: 85.7%). Two (28.6%) patients died during the hospital stay, one patient with unsuccessful thrombectomy and the other due to pneumonia. In all survivors control echocardiography demonstrated normalised function of the right ventricle. Also, dyspnoea disappeared and blood gas parameters normalised. There was no recurrent thromboembolism during 3-14 months of follow-up. Conclusions In the Polish setting, in selected patients, management of high- and intermediate-risk pulmonary embolism with PMPT is technically feasible. Such treatment is relatively safe and effective. It can be an alternative to standard management, especially in patients with contraindications for fibrinolysis or surgical embolectomy.
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18
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Li XF, Wan CQ, He XG, Qiu JY, Li DY, Sun YX, Mao YM. Catheter-directed therapy as a treatment for submassive pulmonary embolism: A meta-analysis. Life Sci 2017; 188:17-25. [PMID: 28864224 DOI: 10.1016/j.lfs.2017.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/21/2017] [Accepted: 08/29/2017] [Indexed: 12/28/2022]
Abstract
AIMS Catheter-directed therapy (CDT) is included in the guidelines for diagnosing and treating massive pulmonary embolism. However, few studies have evaluated the efficacy of CDT as a treatment for submassive pulmonary embolism (SPE). Therefore, we used evidence-based medicine to evaluate the effectiveness and safety of CDT in treating SPE. METHODS Search terms describing CDT in SPE and patients with intermediate pulmonary embolism were entered into the PubMed, Embase and Cochrane Library databases to identify relevant articles without language restrictions published between January 1990 and December 2016. A quality assessment and data extraction were performed by two investigators. The clinical efficacy of and major complications associated with treatment were analysed using a fixed effects model. KEY FINDINGS A total of 552 patients in 16 studies were included in this meta-analysis. The clinical success rate in CDT was approximately 100% (95% confidence interval (CI): 99%, 100%), the primary bleeding rate was 0.02% (95% CI: 0%, 0.05%), and mortality during hospitalization was approximately 0% (95% CI: 0%, 0.01%). The mean decrease in pulmonary artery systolic pressure after treatment was -14.9% (95% CI: -19.25%, -10.55%), and the mean post-treatment change in the ratio of the right to the left ventricle (RV/LV) was -0.35% (95% CI: -0.48%, -0.22%). SIGNIFICANCE CDT is effective and safe as a treatment for SPE and could be a first-line treatment for SPE under specific conditions.
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Affiliation(s)
- Xiao-Fang Li
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China.
| | - Cheng-Quan Wan
- Department of Neonatology, The Women and Children Health Care Center of Luoyang, Henan Province, China
| | - Xue-Gai He
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Jia-Yong Qiu
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Dan-Yang Li
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Yu-Xia Sun
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Yi-Min Mao
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
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Abstract
Pulmonary embolism (PE) in the pediatric population is relatively rare when compared to adults; however, the incidence is increasing and accurate and timely diagnosis is critical. A high clinical index of suspicion is warranted as PE often goes unrecognized among children leading to misdiagnosis and potentially increased morbidity and mortality. Evidence-based guidelines for the diagnosis, management, and follow-up of children with PE are lacking and current practices are extrapolated from adult data. Treatment options include thrombolysis and anticoagulation with heparins and oral vitamin K antagonists, with newer direct oral anticoagulants currently in clinical trials. Long-term sequelae of PE, although studied in adults, are vastly unknown among children and adolescents. Additional research is needed in order to provide pediatric focused care for patients with acute PE.
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Affiliation(s)
- Ahmar Urooj Zaidi
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
| | - Kelley K Hutchins
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
| | - Madhvi Rajpurkar
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
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20
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Guo J, Gu Y, Guo L, Tong Z, Gao X. Angiojet rheolytic thrombectomy combined with catheter fragmentation in a patient presenting with massive pulmonary embolism and cardiogenic shock. Technol Health Care 2016; 25:157-161. [PMID: 27689561 DOI: 10.3233/thc-161262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Massive pulmonary embolism (MPE) is associated with a high rate of mortality, and chronic thromboembolic pulmonary hypertension leads to ongoing morbidity among many survivors. Here we report a case of a MPE successfully treated by Angiojet rheolytic thrombectomy combined with catheter fragmentation. This is the first report of the use of these two methods together for MPE treatment.
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Affiliation(s)
- Jianming Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, China.,Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Yongquan Gu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, China.,Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Lianrui Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, China.,Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Zhu Tong
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, China.,Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Xixiang Gao
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, China.,Institute of Vascular Surgery, Capital Medical University, Beijing, China
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21
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Latacz P, Simka M, Ludyga T, Popiela TJ, Mrowiecki T. Endovascular thrombectomy with the AngioJet System for the treatment of intermediate-risk acute pulmonary embolism: a case report of two patients. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2016; 12:61-4. [PMID: 26966452 PMCID: PMC4777709 DOI: 10.5114/pwki.2016.56952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/20/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Paweł Latacz
- Department of Vascular Surgery, University Hospital, Krakow, Poland
| | - Marian Simka
- Department of Nursing, College of Applied Sciences, Ruda Śląska, Poland
| | - Tomasz Ludyga
- Department of Vascular Surgery, EuroMedic, Katowice, Poland
| | - Tadeusz J. Popiela
- Department of Radiology, Emergency and Mass-Event Medicine, Trauma Centre, University Hospital, Krakow, Poland
| | - Tomasz Mrowiecki
- Department of Vascular Surgery, University Hospital, Krakow, Poland
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22
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Avgerinos ED, Chaer RA. Catheter-directed interventions for acute pulmonary embolism. J Vasc Surg 2015; 61:559-65. [DOI: 10.1016/j.jvs.2014.10.036] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 10/16/2014] [Indexed: 01/29/2023]
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23
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Combined rheolytic thrombectomy and stent placement in SVC and brachiocephalic vein thrombosis due to metastatic lymphadenopathy. Radiol Case Rep 2015; 10:991. [PMID: 27408654 PMCID: PMC4921187 DOI: 10.2484/rcr.v10i1.991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The current management of neoplastic obstruction, SVC, and brachiocephalic vein thrombosis, especially of SVC, is based on the combined use of interventional (endovascular thrombolysis or thrombectomy, stent placement) and noninterventional (radiation, chemotherapy) means of treatment. We present the case of a forty-year-old woman with SVC and left brachiocephalic vein thrombosis secondary to lymph node metastasis of non-small-cell lung cancer. A combination of rheolytic thrombectomy (Angiojet device) and stent placement was performed for both venous sites with complete technical success. We discuss the principles of percutaneous rheolytic thrombectomy, its effectiveness, and potential complications.
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24
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Trombectomia percutânea reolítica no tratamento de tromboembolismo pulmonar de alto risco: experiência inicial de um centro. Rev Port Cardiol 2014; 33:371-7. [DOI: 10.1016/j.repc.2014.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 01/28/2014] [Accepted: 02/01/2014] [Indexed: 11/22/2022] Open
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Faria R, Oliveira M, Ponte M, Pires-Morais G, Sousa M, Fernandes P, Rodrigues A, Braga P, Gonçalves M, Gama V. Percutaneous thrombectomy in the treatment of acute pulmonary embolism: Initial experience of a single center. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2014.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Chon MK, Park YH, Choi JH, Lee SH, Kim JS, Kim J, Kim JH, Chun KJ. Thrombolytic therapy complemented by ECMO: successful treatment for a case of massive pulmonary thromboembolism with hemodynamic collapse. J Korean Med Sci 2014; 29:735-8. [PMID: 24851033 PMCID: PMC4024947 DOI: 10.3346/jkms.2014.29.5.735] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 10/17/2013] [Indexed: 12/16/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is a common clinical condition related to significant mortality. Furthermore, patients with PTE presenting with right heart thrombus show higher mortality due to rapid hemodynamic deterioration. But the optimal treatment of massive PTE is controversial although various methods have been developed and improved. Here, we presented a case of 56-yr-old woman with massive PTE showing hemodynamic collapse, who was successfully treated with extracorporeal membrane oxygenation (ECMO) adjunct to thrombolytic therapy even without thrombectomy. ECMO was useful for resuscitation and stabilization of the cardiopulmonary function. In conclusion, thrombolytic therapy complemented by ECMO may be an effective treatment option for acute massive PTE with hemodynamic instability.
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Affiliation(s)
- Min Ku Chon
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yong Hyun Park
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jin Hee Choi
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Su Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jun Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - June Hong Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kook Jin Chun
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Lee L, Kavinsky CJ, Spies C. Massive pulmonary embolism: review of management strategies with a focus on catheter-based techniques. Expert Rev Cardiovasc Ther 2014; 8:863-73. [DOI: 10.1586/erc.10.52] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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28
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Abstract
PURPOSE OF REVIEW The goal of this review is to offer an overview of the use of thrombolytic therapy in acute pulmonary embolism. Clinicians including internists, surgeons, pulmonologists, and other specialists continue to face decisions regarding massive and submassive acute pulmonary embolism in their daily routines. Although an evidence base exists, unanswered questions remain regarding the use of thrombolytic agents. RECENT FINDINGS Few large, randomized trials exist in this area of medicine and unanswered questions remain. However, guidelines have been modified and new guidelines have been published over the past several years. Recent data indicating that lower doses of tissue plasminogen activator may be effective and safer are discussed. Newer thrombolytic agents may have advantages, but are less well studied. SUMMARY Thrombolytic therapy results in the accelerated lysis of acute pulmonary embolism. However, because nonpathologic thrombi are also lysed, these drugs, although potentially lifesaving, can cause significant bleeding complications. Massive acute pulmonary embolism is the clearest indication for the administration of thrombolytic agents, but patients with acute pulmonary embolism and significant compromise in the absence of hypotension may also merit consideration.
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29
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Bonvini RF, Roffi M, Bounameaux H, Noble S, Müller H, Keller PF, Jolliet P, Sarasin FP, Rutschmann OT, Bendjelid K, Righini M. AngioJet rheolytic thrombectomy in patients presenting with high-risk pulmonary embolism and cardiogenic shock: a feasibility pilot study. EUROINTERVENTION 2013; 8:1419-27. [DOI: 10.4244/eijv8i12a215] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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Nicholson GT, Kogon B, Vincent R. AngioJet rheolytic thrombectomy in a neonate with pulmonary artery thrombus. Catheter Cardiovasc Interv 2013; 82:E704-7. [PMID: 23420640 DOI: 10.1002/ccd.24740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 10/29/2012] [Indexed: 11/08/2022]
Abstract
A newborn infant with obstructed supracardiac total anomalous pulmonary venous return underwent emergent surgical correction on day of life 0. A surgically placed transthoracic pulmonary artery catheter was used to monitor pulmonary artery pressure and removed on postoperative day 3. Following acute deterioration in respiratory status requiring reintubation, echocardiographic assessment demonstrated findings consistent with pulmonary hypertension and diminished flow to the left lung. Cardiac catheterization confirmed elevated pulmonary artery pressure and near complete occlusion of his left pulmonary artery due to a thrombus. He underwent successful percutaneous catheter-based thrombectomy using the AngioJet rheolytic catheter, recovered fully, and was discharged home on postoperative day 30. Although thrombotic events resulting in respiratory and hemodynamic compromise are rare in infants, recognition is important and treatment using mechanical thrombectomy can be life saving.
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Affiliation(s)
- George T Nicholson
- Division of Pediatric Cardiology and Department of Pediatrics, Emory University, Atlanta, Georgia
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31
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Bunwaree S, Roffi M, Bonvini JM, Noble S, Righini M, Bonvini RF. AngioJet ®rheolytic thrombectomy: a new treatment option in cases of massive pulmonary embolism. Interv Cardiol 2013. [DOI: 10.2217/ica.12.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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32
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Ko CH, Forrest P, D’Souza R, Qasabian R. Successful use of extracorporeal membrane oxygenation in a patient with combined pulmonary and systemic embolisation. Perfusion 2012; 28:138-40. [DOI: 10.1177/0267659112463163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- C-H Ko
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - P Forrest
- Cardiothoracic Anaesthesia and Perfusion. Royal Prince Alfred Hospital, Camperdown, NSW. Clinical Associate Professor, University of Sydney, Sydney, Australia
| | - R D’Souza
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - R Qasabian
- Vascular Surgery. Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Tan TW, Bohannon WT, Mattos MA, Hodgson KJ, Farber A. Percutaneous mechanical thrombectomy and pharmacologic thrombolysis for renal artery embolism: case report and review of endovascular treatment. Int J Angiol 2012; 20:111-6. [PMID: 22654475 DOI: 10.1055/s-0031-1279682] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Renal artery embolism (RAE) is an uncommon event that is associated with a high rate of renal loss. We present a case of RAE to a solitary kidney that was treated with combined percutaneous rheolytic thrombectomy, intra-arterial thrombolysis, and supplemental renal artery stent placement.
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Abstract
BACKGROUND Catheter thrombectomy combining thrombus destruction with local thrombolysis has been used in patients with pulmonary embolism (PE) who are unstable or have significant right heart dysfunction, but have contraindications to systemic thrombolytic therapy. OBJECTIVES To assess the outcomes of patients who underwent pulmonary embolectomy using a commercially available thrombectomy device. METHODS A retrospective chart review of patients who underwent pulmonary embolectomy between March 2007 and August 2009 was performed. Patients were classified as having clinical massive or submassive PE, and moderate or severe right ventricular dysfunction. Data collected included pre- and postprocedure shock index (heart rate divided by systolic blood pressure) and mean pulmonary artery pressure. RESULTS Sixteen patients with a mean (± SD) age of 54.4 ± 15.8 years underwent embolectomy. Five had clinical massive PE (two in cardiogenic shock) and three of 11 submassive cases had severe right ventricular dysfunction. All were deemed to have contraindications to systemic lysis. Both shock index (1.02 ± 33 preintervention versus 0.71 ± 0.2 postintervention [P=0.001]) and mean pulmonary artery pressure (34.5 ± 9.9 mmHg preintervention versus 27.1 ± 7.1 postintervention [P=0.01]) improved. In the massive PE group, one patient died and two survivors experienced retroperitoneal bleeding and transient renal failure. At follow-up (17.3 ± 7.8 months), two patients in the massive PE group demonstrated evidence of mild cor pulmonale. CONCLUSION Rheolytic thrombectomy is an effective strategy in managing massive PE, particularly in patients who have well-defined contraindications to systemic lytic therapy. The effectiveness of rheolytic thrombectomy for submassive PE is not as well defined, but warrants a comparison with systemic lytic therapy.
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Tapson VF. Advances in the diagnosis and treatment of acute pulmonary embolism. F1000 MEDICINE REPORTS 2012; 4:9. [PMID: 22619694 PMCID: PMC3357009 DOI: 10.3410/m4-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Over the past two decades, considerable progress in technology and clinical research methods have led to advances in the diagnosis, treatment and prevention of acute venous thromboembolism. Despite this, however, the diagnosis is still often missed and preventive methods are often ignored. Published guidelines are useful, but are limited by the existing evidence base so that controversies remain with regard to topics such as duration of anticoagulation, indications for placement and removal of inferior vena caval filters, and when and how to administer thrombolytic therapy. The morbidity and mortality of this disease remain high, particularly when undiagnosed. While preventive approaches remain crucial, the focus of this review is on the diagnostic and therapeutic approach to acute venous thromboembolism, with an emphasis on acute pulmonary embolism.
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Affiliation(s)
- Victor F Tapson
- Division of Pulmonary and Critical Care Director, Center for Pulmonary Vascular Disease, Duke University Medical Center Durham, NC 27710 USA
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Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S-e496S. [PMID: 22315268 PMCID: PMC3278049 DOI: 10.1378/chest.11-2301] [Citation(s) in RCA: 2482] [Impact Index Per Article: 206.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This article addresses the treatment of VTE disease. METHODS We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence. RESULTS For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C). CONCLUSION Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.
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Affiliation(s)
- Clive Kearon
- Department of Medicine and Clinical Epidemiology and Biostatistics, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Medicine, Family Medicine, and Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY.
| | | | - Paolo Prandoni
- Department of Cardiothoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Henri Bounameaux
- Department of Medical Specialties, University Hospitals of Geneva, Geneva, Switzerland
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael E Nelson
- Department of Medicine, Shawnee Mission Medical Center, Shawnee Mission, KS
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michael K Gould
- Department of Medicine and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Mark Crowther
- Department of Medicine, Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Susan R Kahn
- Department of Medicine and Clinical Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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Endovascular therapy for acute pulmonary embolism. J Vasc Interv Radiol 2011; 23:167-79.e4; quiz 179. [PMID: 22192633 DOI: 10.1016/j.jvir.2011.10.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Revised: 10/14/2011] [Accepted: 10/16/2011] [Indexed: 12/24/2022] Open
Abstract
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.
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Vanni S, Nazerian P, Pepe G, Baioni M, Risso M, Grifoni G, Viviani G, Grifoni S. Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach. J Thromb Haemost 2011; 9:1916-23. [PMID: 21819540 DOI: 10.1111/j.1538-7836.2011.04459.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recently, some prognostic models for acute pulmonary embolism (PE) have been proposed. We investigated whether the Pulmonary Embolism Severity Index (PESI) and the European Society of Cardiology (ESC) prognostic approaches result in different prognoses. METHODS Consecutive adult patients with acute PE were included. According to the ESC guidelines, high-risk patients were identified by the presence of shock/hypotension, intermediate-risk patients by elevated troponin I or right ventricular dysfunction as assessed by echocardiography, and low-risk patients by the absence of any of the above. In the PESI model, 11 clinical variables, easily accessible at the bedside, were used to generate three risk classes. The main outcomes were all-cause and PE-related in-hospital mortality. RESULTS Forty-one patients (8%, 95% confidence interval [CI] 5.8-10.8) of 510 died. According to the ESC model, 40% were at low risk of short-term mortality, 54% at intermediate risk, and 6% at high risk. The distribution according to the PESI model was 31% (P < 0.05 vs. ESC), 49% and 20% (P < 0.05 vs. ESC), respectively. Mortality increased through the risk classes (P < 0.01), without significant differences between the models. The ESC model identified with higher accuracy than the PESI model both high-risk and low-risk patients (P < 0.05 for both). When patients with shock/hypotension were excluded, the PESI model stratified patients into classes with increasing PE-related mortality (0.7%, 4.3%, and 11.6%, P < 0.05). Troponin I and right ventricular dysfunction added incremental prognostic value to the PESI model, particularly in normotensive patients at intermediate risk. CONCLUSIONS The ESC model showed higher accuracy than the PESI model in identifying high-risk and low-risk patients. In normotensive patients, the PESI model could guide clinical management as well as troponin I and echocardiography testing.
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Affiliation(s)
- S Vanni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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39
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Treatment of pulmonary embolism: anticoagulation, thrombolytic therapy, and complications of therapy. Crit Care Clin 2011; 27:825-39, vi. [PMID: 22082516 DOI: 10.1016/j.ccc.2011.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
During the last two decades, considerable progress in technology and clinical research methods have led to advances in the approach to the diagnosis, prevention, and treatment of acute venous thromboembolism (VTE). Despite this, however, the diagnosis is often delayed and preventive methods are often ignored. Thus, the morbidity and mortality associated with VTE remain high. The therapeutic approach to acute VTE is discussed in this article, with a particular focus on the intensive care unit setting.
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40
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Collapse of Viabahn Stent-Graft Secondary to Rheolytic Thrombectomy: A Rare Complication of the AngioJet Device. Ann Vasc Surg 2011; 25:557.e15-7. [DOI: 10.1016/j.avsg.2010.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 09/28/2010] [Indexed: 11/20/2022]
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Tapson VF. Interventional therapies for venous thromboembolism: vena caval interruption, surgical embolectomy, and catheter-directed interventions. Clin Chest Med 2011; 31:771-81. [PMID: 21047582 DOI: 10.1016/j.ccm.2010.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Therapeutic strategies other than anticoagulation sometimes require consideration in the setting of acute venous thromboembolism. Vena caval filter placement is increasingly common, in part because of the availability of nonpermanent filter devices. Filter placement, surgical embolectomy, and catheter embolectomy have not been subjected to the same prospective, randomized clinical trial scrutiny as anticoagulation but seem appropriate in certain clinical settings. The indications, contraindications, and available data supporting these therapeutic methods are discussed.
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Affiliation(s)
- Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Room 351, Bell Building, Box 31175, Duke University Medical Center, Durham, NC, 27710, USA.
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42
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Tsuji A, Yamada N, Ota S, Ishikura K, Nakamura M, Ito M. Early Results of Rheolytic Thrombectomy in Patients With Proximal Deep Vein Thrombosis. Circ J 2011; 75:1742-6. [PMID: 21597205 DOI: 10.1253/circj.cj-10-0617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiro Tsuji
- Department of Cardiology, Mie University Graduate School of Medicine
| | - Norikazu Yamada
- Department of Cardiology, Mie University Graduate School of Medicine
| | - Satoshi Ota
- Department of Cardiology, Mie University Graduate School of Medicine
| | - Ken Ishikura
- Department of Cardiology, Mie University Graduate School of Medicine
| | - Mashio Nakamura
- Department of Cardiology, Mie University Graduate School of Medicine
| | - Masaaki Ito
- Department of Cardiology, Mie University Graduate School of Medicine
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Hershberger RC, Bornak A, Aulivola B, Mannava K. Acute Pancreatitis after Percutaneous Mechanical Thrombectomy: Case Report and Review of the Literature. Cardiovasc Intervent Radiol 2010; 34 Suppl 2:S25-30. [DOI: 10.1007/s00270-010-0027-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 10/20/2010] [Indexed: 11/28/2022]
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44
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Percutaneous Treatment of Biliary Cast Syndrome After Orthotopic Liver Transplantation: Comparison of Mechanical Versus Hydraulic Rheolytic Cast Extraction. Cardiovasc Intervent Radiol 2010; 34:998-1005. [DOI: 10.1007/s00270-010-9998-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 09/09/2010] [Indexed: 12/12/2022]
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46
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Fleming GA, Khan M, Janssen D, Doyle T. Angiojet rheolytic thrombectomy in infants following cardiac surgery. Catheter Cardiovasc Interv 2010; 76:233-40. [DOI: 10.1002/ccd.22544] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Affiliation(s)
- Thomas M Todoran
- Cardiovascular Division, Vascular Medicine Section, Brigham and Women's Hospital, Boston, MA 02115, USA
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48
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Lin PH, Annambhotla S, Bechara CF, Athamneh H, Weakley SM, Kobayashi K, Kougias P. Comparison of percutaneous ultrasound-accelerated thrombolysis versus catheter-directed thrombolysis in patients with acute massive pulmonary embolism. Vascular 2010; 17 Suppl 3:S137-47. [PMID: 19919804 DOI: 10.2310/6670.2009.00063] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acute massive pulmonary embolism (PE) is a life-threatening condition that requires prompt and aggressive interventions, including anticoagulation, catheter-directed thrombolysis (CDT), mechanical thrombectomy, or surgical thromboembolectomy. The aim of this study was to evaluate the treatment outcome in patients with massive PE who were treated with either ultrasound-accelerated thrombolysis using the EkoSonic Endovascular System (EKOS) or CDT intervention. During a recent 10-year period, the clinical records of all patients with massive PE undergoing catheter-directed interventions were evaluated. Patients were divided into two treatment groups: EKOS versus CDT interventions. Comparisons were made with regard to the treatment outcome between the two groups. Twenty-five patients underwent 33 catheter-directed interventions for massive PE during the study period. Among them, EKOS or CDT was performed in 15 (45%) and 18 (55%) procedures, respectively. In the EKOS group, complete thrombus removal was achieved in 100% cases. In the CDT cohort, complete or partial thrombus removal was accomplished in 7 (50%) and 2 (14%) cases, respectively. Comparing treatment success based on thrombus removal, EKOS treatment resulted in an improved treatment outcome compared with the CDT group (p < .02). The mean time of thrombolysis in EKOS and CDT group was 17.4 +/- 5.23 and 25.3 +/- 7.35 hours, respectively (p = .03). The mortality rate in the EKOS and CDT group was 9.1% and 14.2%, respectively (not significant). Treatment-related hemorrhagic complication rates in the EKOS and CDT group were 0% and 21.4%, respectively (p = .02). A significant reduction in Miller scores was noted in both groups following catheter-based interventions. No significant difference in relative Miller score improvement was observed between groups. Ultrasound-accelerated thrombolysis using the EkoSonic system is an effective treatment modality in patients with acute massive PE. When compared with CDT, this treatment modality provides similar treatment efficacy with reduced thrombolytic infusion time and treatment-related complications.
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Affiliation(s)
- Peter H Lin
- Division of Vascular Surgery and Endovascular Therapy, Michael E, DeBakey Department of Surgery, Baylor College of Medicine, 1709 Dryden Road, Suite 1500, Houston, TX 77030, USA.
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Porres-Aguilar M, Munoz OC, Alvarez P, Gonzalez-Ayala E. Successful percutaneous mechanical thrombectomy in a haemodynamically unstable patient with massive pulmonary embolism. Respirology 2010; 15:576-9. [PMID: 20146754 DOI: 10.1111/j.1440-1843.2010.01717.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Massive pulmonary embolism with haemodynamic instability has a high mortality. Traditionally these patients are treated with i.v. thrombolytic therapy. When this therapeutic approach is contraindicated, surgical embolectomy and most recently, percutaneous mechanical interventions are alternative treatment options. This case report presents a 73-year-old female with a residual hemiparesis secondary to a meningioma resection 45 days previously, who presented with progressive shortness of breath, accompanied by oppressive chest pain, hypotension, tachycardia and severe hypoxaemia. CT pulmonary angiogram confirmed a massive pulmonary embolism extending into the lobar branches bilaterally. The patient was treated with percutaneous mechanical thrombectomy with excellent haemodynamic and clinical outcomes.
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Affiliation(s)
- Mateo Porres-Aguilar
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah Health Sciences Center/School of Medicine, Salt Lake City, Utah 84132, USA.
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Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol 2010; 20:1431-40. [PMID: 19875060 DOI: 10.1016/j.jvir.2009.08.002] [Citation(s) in RCA: 319] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 07/15/2009] [Accepted: 08/03/2009] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- William T Kuo
- Division of Vascular and Interventional Radiology, Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr, H-3630, Stanford, CA 94305-5642, USA.
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