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Noman A, Stegman B, DuCoffe AR, Bhat A, Hoban K, Bunte MC. Episode Care Costs Following Catheter-Directed Reperfusion Therapies for Pulmonary Embolism: A Literature-Based Comparative Cohort Analysis. Am J Cardiol 2024; 225:178-189. [PMID: 38871160 DOI: 10.1016/j.amjcard.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/17/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
This analysis aimed to estimate 30-day episode care costs associated with 3 contemporary endovascular therapies indicated for treatment of pulmonary embolism (PE). Systematic literature review was used to identify clinical research reporting costs associated with invasive PE care and outcomes for ultrasound-accelerated thrombolysis (USAT), continuous-aspiration mechanical thrombectomy (CAMT), and volume-controlled-aspiration mechanical thrombectomy (VAMT). Total episode variable care costs were defined as the sum of device costs, variable acute care costs, and contingent costs. Variable acute care costs were estimated using methodology sensitive to periprocedural and postprocedural resource allocation unique to the 3 therapies. Contingent costs included expenses for thrombolytics, postprocedure bleeding events, and readmissions through 30 days. Through February 28, 2023, 70 sources were identified and used to inform estimates of 30-day total episode variable costs. Device costs for USAT, CAMT, and VAMT were the most expensive single component of total episode variable costs, estimated at $5,965, $10,279, and $11,901, respectively. Costs associated with catheterization suite utilization, intensive care, and hospital length of stay, along with contingent costs, were important drivers of total episode costs. Total episode variable care costs through 30 days were $19,146, $20,938, and $17,290 for USAT, CAMT, and VAMT, respectively. In conclusion, estimated total episode care costs after invasive treatment for PE are heavily influenced by device expense, in-hospital care, and postacute care complications. Regardless of device cost, strategies that avoid thrombolytics, reduce the need for intensive care unit care, shorten length of stay, and reduce postprocedure bleeding and 30-day readmissions contributed to the lowest episode costs.
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Affiliation(s)
- Anas Noman
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Brian Stegman
- Department of Cardiology, CentraCare Heart and Vascular Center, St. Cloud, Minnesota
| | - Aaron R DuCoffe
- Department of Radiology, Inova Health System, Fairfax, Virginia
| | - Ambarish Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri
| | - Kyle Hoban
- Department of Scientific Affairs, Inari Medical Inc, Irvine, California
| | - Matthew C Bunte
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Cardiology, Saint Luke's Hospital of Kansas City, Kansas City, Missouri.
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Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med 2022; 11:jcm11164807. [PMID: 36013046 PMCID: PMC9409943 DOI: 10.3390/jcm11164807] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
- Correspondence:
| | - Julien Behr
- Department of Radiology, University Hospital Besançon, 25000 Besancon, France
| | - Charles Vidoni
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
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3
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Schreinlechner M, Geiger R, Mair J. Ultrasound-assisted catheter-directed thrombolysis for successful rescue treatment of acute pulmonary embolism in decompensated Fontan palliation. J Cardiol Cases 2022; 25:326-329. [PMID: 35685255 PMCID: PMC9168972 DOI: 10.1016/j.jccase.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/24/2021] [Accepted: 12/03/2021] [Indexed: 11/20/2022] Open
Abstract
A 22-year-old woman with complete Fontan palliation for tricuspid valve hypoplasia and chronic anemia presented to a local hospital for swelling of her left arm. Initially, the patient was hemodynamically stable without dyspnea or chest pain. Admission hemoglobin was 53 g/L and D-dimer 0.51 mg/L. Sonography showed signs of venous congestion of the left arm, but no definitive signs of venous thrombosis. Subsequently she developed dyspnea with a decrease in transcutaneous oxygen saturation to 85%. Computed tomography angiography revealed bilateral pulmonary embolism with occlusion of the right pulmonary artery. The patient was transferred to a tertiary care center. Gastroscopy detected only small stomach ulcers, and because of ongoing hemodynamic instability, the decision was to initiate rescue ultrasound-assisted catheter-directed local thrombolysis. This treatment was effective with rapid hemodynamic stabilization without bleeding complications and without residual emboli in a long-term follow-up cardiac catheterization. .
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Affiliation(s)
- Michael Schreinlechner
- Department of Internal Medicine III – Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | - Ralf Geiger
- Department of Child and Adolescent Health, Pediatrics III – Cardiology and Pulmology, Medical University Innsbruck, Innsbruck, Austria
| | - Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
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Chopard R, Meneveau N, Ecarnot F. Catheter-based therapy for acute pulmonary embolism: An overview of current evidence. Arch Cardiovasc Dis 2022; 115:397-405. [DOI: 10.1016/j.acvd.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/15/2022] [Accepted: 06/01/2022] [Indexed: 11/26/2022]
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Krishnan AM, Gadela NV, Ramanathan R, Jha A, Perkins ME, Metersky ML. A Comparative Analysis of Catheter Directed Thrombolysis with Anticoagulation Alone or Systemic tPA in Acute Pulmonary Embolism with Cor Pulmonale. J Intensive Care Med 2022; 37:1336-1343. [DOI: 10.1177/08850666221083241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Pulmonary embolism (PE) with cor pulmonale causes considerable mortality and morbidity. Randomized trials have failed to show a mortality difference between treatment modalities including anticoagulation (AC), Catheter directed thrombolysis (CDT) and systemic tPA (tissue plasminogen activator). Methods This is a cross-sectional retrospective case-control study utilizing the 2017 National Inpatient Sample (NIS). Patients admitted with acute PE with cor pulmonale were divided into groups based on whether they received anticoagulation, CDT or systemic tPA based on appropriate ICD-10 PCS codes. The AC group and CDT group were compared using univariate and multivariate analyses after adjusting for age, gender, race, comorbidities, insurance status and Charlson comorbidity index (CCI). Secondary outcomes included factors influencing length of stay (LOS) and total charges incurred. Similar analyses were done to compare the CDT group with the tPA group. Results In 2017, 13240 patients were admitted with acute PE and cor pulmonale, of whom 18% underwent CDT, 10% underwent systemic tPA and 72% underwent AC alone. Patients who received CDT over AC alone were significantly younger (61.5 vs. 65.5, p = 0.00). Mortality rate overall was 4.8% with tPA group, CDT group and AC alone group having a 11.2%, 3.0% and 4.4% mortality rate respectively. On multivariate analyses, there was no significant mortality difference between the CDT and AC groups (aOR 0.61, 0.34-1.1 95%CI, p = 0.103). Patients with liver disease had significantly higher mortality while obese patients had a significantly lower mortality after adjusting for treatment strategy and confounders. Length of stay (LOS) was not significantly different between the groups however, compared to AC alone, patients who underwent CDT or tPA incurred significantly higher total hospital charges. Conclusions CDT offers an attractive alternative to tPA therapy; however, our study does not show an in-hospital mortality benefit. More studies are required to guide patient selection prior to establishing treatment protocols.
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Affiliation(s)
- Anand Muthu Krishnan
- Department of Cardiovascular Disease, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Naga Vaishnavi Gadela
- Department of Internal Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Rudra Ramanathan
- Department of Pulmonology and Critical Care Disease, NYU Langone, NY
| | - Anil Jha
- Department of Internal Medicine, Lawrence General Hospital, Boston, Massachusetts, USA
| | - Michael E. Perkins
- Department of Pulmonology and Critical Care, Hartford Hospital, Hartford, Connecticut, USA
| | - Mark L. Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, Farmington
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Schmitz A, Schacht M, Butty S. Repeat angiography in patients undergoing conventional catheter-directed thrombolysis for submassive pulmonary embolism: a large single-center experience. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:664-670. [PMID: 34559051 DOI: 10.5152/dir.2021.20573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Few studies have examined conventional catheter directed thrombolysis (CDT) for the treatment of submassive pulmonary embolism (PE). Moreover, angiographic resolution of thrombus burden following CDT has infrequently been characterized. This study describes a single-center experience treating submassive PE with CDT while utilizing repeat angiography to determine treatment efficacy. METHODS A retrospective analysis of 140 consecutive patients who underwent CDT for submassive PE from December 2012 to June 2019 was performed. Angiographic resolution of thrombus burden after CDT was reported as high (>75%), moderate (51-75%), low (26-50%), or insignificant (≤25%). All angiograms were reviewed by two interventional radiologists. Secondary endpoints included reduction in pulmonary artery pressure (PAP) and clinical outcomes. Bleeding events were classified according to the Society of Interventional Radiology (SIR) adverse event criteria. RESULTS CDT was performed in 140 patients with a mean rtPA dose of 25.3 mg and a mean treatment time of 26.0 hours. Angiographic resolution of thrombus burden was high in 70.0%, moderate in 19.3%, low in 5.7%, and insignificant in 3.6%; in 2 patients (1.4%) repeat angiography was not performed. Systolic PAP was reduced (47 vs. 35 mmHg, p < 0.001), mean PAP was reduced (25 vs 21 mmHg, p < 0.001), and 129 patients (92.1%) improved clinically. Patients with high or moderate resolution of thrombus burden had a clinical improvement rate of 95.2%, while patients with low or insignificant thrombus burden resolution had a clinical improvement rate of 76.9% (p=0.011). Ten patients (7.1%) had hemodynamic or respiratory decompensation requiring mechanical ventilation, systemic thrombolysis, cardiopulmonary resuscitation, or surgical intervention. Seven patients (5.0%) experienced moderate bleeding events and one patient (0.7%) with metastatic disease developed severe gastrointestinal bleeding that resulted in death. Thirty-day mortality was 1.4%. CONCLUSION In patients with submassive PE undergoing CDT, angiographic resolution of thrombus burden is a safe and directly observable metric that can be used to determine procedural success. In this study, CDT with repeat angiography was associated with a 5.7% bleeding event rate and thirty-day mortality of 1.4%.
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Affiliation(s)
- Adam Schmitz
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
| | - Michael Schacht
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
| | - Sabah Butty
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, US
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Jiang C, Xie M. Clinical Outcomes of Intermediate-Risk Pulmonary Embolism Across a Northeastern Health System: A Multi-Center Retrospective Cohort Study. Cureus 2021; 13:e15888. [PMID: 34336410 PMCID: PMC8312800 DOI: 10.7759/cureus.15888] [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: 05/09/2020] [Accepted: 06/24/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The role of thrombolytic therapy in the management of intermediate-risk pulmonary embolism is controversial. Our objective was to determine clinical outcomes for a population of patients with intermediate-risk pulmonary embolism receiving anticoagulation with and without thrombolytic therapy in a large Northeastern health system. DESIGN A retrospective cohort study. SETTING ICU and non-ICU settings in 8 hospitals. PATIENTS Hemodynamically stable patients with intermediate-risk pulmonary embolism. INTERVENTIONS Treatment arms were anticoagulation (AC) alone, AC with low dose intravenous thrombolysis, AC with full-dose intravenous thrombolysis, and AC with ultrasound-assisted, catheter-directed thrombolysis. MEASUREMENTS AND MAIN RESULTS In 257 patients, utilizing a Bonferroni corrected P value cutoff of α = 0.003, our data shows no differences in 7 day or 30 day all-cause mortality (α = 0.37 and α = 0.04, respectively) , hospital length of stay (α = 0.31), 7 or 30 readmission rates (α = 0.97 and α = 0.84, respectively), or any major (α = 0.82) or minor bleeding events (α = 0.007) among the four treatment groups. Use of anticoagulation alone was associated with a lower duration of ICU stay (α < 0.001). There was a significant decrease in the secondary outcome of one year all-cause mortality in favor of full dose and catheter-directed thrombolytic treatment (α = 0.003). Pulmonary artery systolic pressure of > 70 mmHg was associated with increased 7-day mortality (OR 7.79, P = 0.048), and systolic blood pressure < 130 (OR 23.0; P = 0.003) and elevated N-terminal pro-B-type natriuretic peptide > 1400 pg/nl (OR 15.33; P = 0.01) were associated with increased 30- day mortality. CONCLUSIONS The use of thrombolytic therapy is not associated with a mortality benefit in the first 30 days compared to anticoagulation alone in this patient population and is associated with increased utilization of intensive care unit resources. We advocate for a conservative approach utilizing initial anticoagulation alone in a patient diagnosed with intermediate-risk pulmonary embolism.
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Affiliation(s)
- Chuan Jiang
- Internal Medicine, Northwell Health, Manhasset, USA
| | - Meng Xie
- Internal Medicine, Jamaica Hospital Medical Center, Richmond Hill, USA
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8
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Efficacy Estimation of Microbubble-Assisted Local Sonothrombolysis Using a Catheter with a Series of Miniature Transducers. MICROMACHINES 2021; 12:mi12060612. [PMID: 34073428 PMCID: PMC8228781 DOI: 10.3390/mi12060612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
Intravascular ultrasound has good prospects for clinical applications in sonothrombolysis. The catheter-based side-looking intravascular ultrasound thrombolysis (e.g., Ekosonic catheters) used in clinical studies has a high frequency (2 MHz). The lower-frequency ultrasound requires a larger-diameter transducer. In our study, we designed and manufactured a small ultrasound-based prototype catheter that can emit a lower frequency ultrasound (1.1 MHz). In order to evaluate the safety and efficacy of local low-frequency ultrasound-enhanced thrombolysis, a microbubble (MB) was introduced to augment thrombolysis effect of locally delivered low-intensity ultrasound. The results demonstrated that combination of ultrasound and MB realized higher clot lysis than urokinase-only treatment (17.0% ± 1.2% vs. 14.9% ± 2.7%) under optimal ultrasound settings of 1.1 MHz, 0.414 MPa, 4.89 W/cm2, 5% duty cycle and MB concentration of 60 μg/mL. When urokinase was added, the fibrinolysis accelerated by MB and ultrasound resulted in a further increased thrombolysis rate that was more than two times than that of urokinase alone (36.7% ± 5.5% vs. 14.9% ± 2.7%). However, a great quantity of ultrasound energy was required to achieve substantial clot lysis without MB, leading to the situation that temperature accumulated inside the clot became harmful. We suggest that MB-assisted local sonothrombolysis be considered as adjuvant therapy of thrombolytic agents.
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9
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Clinical outcomes of very elderly patients treated with ultrasound-assisted catheter-directed thrombolysis for pulmonary embolism: a systematic review. J Thromb Thrombolysis 2021; 52:260-271. [PMID: 33665765 DOI: 10.1007/s11239-021-02409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
Pulmonary embolism (PE) is a significant cause of death in the very elderly (≥ 75 years) population. Ultrasound-assisted catheter-directed thrombolysis (USCDT) emerges to improve thrombolysis safety and efficacy. However, outcomes in very elderly patients are unknown, as randomized controlled trials exclude this population. Recently, we demonstrated acute kidney injury (AKI) and ischemic hepatitis in an octogenarian intermediate-risk PE patient treated with USCDT. Considering the lack of evidence, we undertook a systematic review to evaluate the clinical outcomes in very elderly PE patients treated with USCDT. We searched for very elderly PE patients treated with USCDT from 2008 to 2019. Additionally, we conducted another systematic review without age restriction to update previous evidence and compare both populations. We also did an exploratory analysis to determine if thrombolysis was followed based on current guidelines or impending clinical deterioration factors. We identified 18 very elderly patients (age 79.2, 75-86), mostly female and with intermediate-risk PE. We found an intracranial hemorrhage (ICH), and a right pulmonary artery rupture. Additionally, two significant bleedings complicated with transient AKI, and one case of AKI and ischemic hepatic injury. The patients who survived all had clinical and echocardiographic in-hospital improvement. Despite low rt-PA doses, ICH and major bleeding remain as feared complications. Thrombolysis decision was driven by impending clinical deterioration factors instead of international guideline recommendations. Our data do not suggest prohibitive risk associated with USCDT in very elderly intermediate and high-risk PE patients. Despite long-term infusions and right ventricular dysfunction, AKI and ischemic hepatic injury were infrequent.
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10
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Stewart LK, Kline JA. Fibrinolytics for the treatment of pulmonary embolism. Transl Res 2020; 225:82-94. [PMID: 32434005 PMCID: PMC7487055 DOI: 10.1016/j.trsl.2020.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/07/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. Fibrinolysis is generally not recommended for routine use in intermediate-risk PE, although most guidelines advise that it may be considered in patients with signs of acute decompensation and an overall low bleeding risk. The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.
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Affiliation(s)
- Lauren K Stewart
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
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11
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Wang CC, Lu CR, Hsieh LC, Lin YK, Chang KC, Hsu CH. Clinical Outcomes of Patients with Intermediate-to-High-Risk Pulmonary Embolism Undergoing Ultrasound-Assisted Catheter-Based Fibrinolysis Therapy in a Mid-Term Follow-Up Period - A Retrospective Observational Study. ACTA CARDIOLOGICA SINICA 2020; 36:493-502. [PMID: 32952359 DOI: 10.6515/acs.202009_36(5).20200330a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives Endovascular therapy with ultrasound-assisted catheter-directed thrombolysis (UACDT) theoretically provides higher efficacy while reducing the bleeding risk compared with conventional systemic thrombolysis. The clinical outcomes of UACDT in treating intermediate-to-high-risk pulmonary embolism (PE) are lacking in an Asian population. Methods Forty-two patients who presented with intermediate-to-high-risk PE received UACDT. The patients were divided into two groups based on the incidence of procedure-related bleeding events, and baseline demographics were compared between the two groups. A paired-Student's t test was conducted to evaluate the efficacy of UACDT. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for significant bleeding events. Results The average age was 58.93 ± 20.48 years, and 33.33% of the study participants were male. A total of 85.7% of the participants had intermediate-risk PE. Compared with pre-intervention pulmonary artery pressure, the mean pulmonary artery pressure decreased significantly (37.61 ± 9.57 mmHg vs. 25.7 ± 9.84 mmHg, p < 0.01) after UACDT. The cumulative total tissue plasminogen activator dosage and total infusion duration were 44.54 ± 20.55 mg and 39.14 ± 19.06 hours respectively. Overall, 21.43% of the participants had severe bleeding events during the endovascular fibrinolysis treatment period. Forward conditional multivariate logistic regression analysis revealed that the lowest fibrinogen level during thrombolysis was an independent factor associated with moderate-to-severe bleeding (odds ratio: 0.40, 95% confidence interval: 0.19-0.88, p = 0.02). Conclusions UACDT exhibited high efficacy, but resulted in a higher-than-expected bleeding rate in this real-world study of an Asian population. The lowest fibrinogen level during thrombolysis was an independent risk factor associated with procedure-related bleeding events.
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Affiliation(s)
- Chun-Cheng Wang
- Graduate Institute of Biomedical Science, China Medical University.,Division of Cardiovascular Medicine, Department of Internal Medicine.,Cardiovascular Research Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Chiung-Ray Lu
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Li-Chuan Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Yu-Kai Lin
- Graduate Institute of Biomedical Science, China Medical University.,Division of Cardiovascular Medicine, Department of Internal Medicine.,Cardiovascular Research Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Cheng Chang
- Graduate Institute of Biomedical Science, China Medical University.,Division of Cardiovascular Medicine, Department of Internal Medicine.,Cardiovascular Research Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Chung-Ho Hsu
- Division of Cardiovascular Medicine, Department of Internal Medicine
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12
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Keenahan LA, Poondla RK, Franklin WJ, Ermis PR, Ketwaroo P, Opina A, Gandhi M. Pulmonary Embolism After Vaginal Delivery in a Fontan Patient. JACC Case Rep 2020; 2:1713-1715. [PMID: 34317041 PMCID: PMC8311981 DOI: 10.1016/j.jaccas.2020.04.051] [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: 03/04/2020] [Accepted: 04/15/2020] [Indexed: 06/13/2023]
Abstract
The Fontan procedure was created to address the mixing of pulmonary and systemic venous return in patients with a single functional ventricle. The patient in this case with a Fontan repair experienced multiple pulmonary emboli 10 days post-partum. We outline management and recommendations when treating these patients. (Level of Difficulty: Beginner.).
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Affiliation(s)
| | | | - Wayne J. Franklin
- Department of Cardiology, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Peter R. Ermis
- Baylor College of Medicine, Houston, Texas
- Adult Congenital Heart Disease Program, Texas Children’s Hospital Houston, Texas
| | - Pamela Ketwaroo
- Baylor College of Medicine, Houston, Texas
- Department of Radiology, Texas Children’s Hospital, Houston, Texas
| | - Angeline Opina
- Baylor College of Medicine, Houston, Texas
- Adult Congenital Heart Disease Program, Texas Children’s Hospital Houston, Texas
| | - Manisha Gandhi
- Baylor College of Medicine, Houston, Texas
- Department of Obstetrics and Gynecology, Texas Children’s Pavilion for Women, Houston, Texas
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13
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Hobohm L, Keller K, Münzel T, Gori T, Konstantinides SV. EkoSonic® endovascular system and other catheter-directed treatment reperfusion strategies for acute pulmonary embolism: overview of efficacy and safety outcomes. Expert Rev Med Devices 2020; 17:739-749. [DOI: 10.1080/17434440.2020.1796632] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH, University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH, University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- Department of Sports Medicine, Internal Medicine VII, Medical Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH, University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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14
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Analysis of pulmonary embolism patients treated with EkoSonic™ endovascular system. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:301-307. [PMID: 32551160 DOI: 10.5606/tgkdc.dergisi.2020.19133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/04/2020] [Indexed: 11/21/2022]
Abstract
Background The aim of this study was to evaluate the efficacy and the safety of the EkoSonic™ endovascular system applications in patients hospitalized with the diagnosis of intermediate-high-risk pulmonary embolism. Methods Between January 2018 and March 2019, a total of 15 patients (7 males, 8 females; mean age 64.7±17.8 years, range, 35 to 90 years) who underwent ultrasound-accelerated thrombolysis using the EkoSonic™ endovascular system for pulmonary embolism were retrospectively analyzed. The diagnosis of pulmonary embolism was made based on pulmonary computed tomography angiography. All patients were evaluated by echocardiography for right ventricular dysfunction and serum levels of troponin I and brain natriuretic peptide were recorded. Results The mean arterial blood gas oxygen saturation values of the patients before and after the procedure were 86.3±3.5% and 94.2±2.5%, respectively, indicating a statistically significant difference (p=0.001). The mean partial oxygen pressure values before and after the procedure were 73.3±7.7 mmHg and 90.7±5.0 mmHg, respectively, indicating a statistically significant difference (p=0.001). There was also a statistically significant difference in the mean right ventricular diameter before and after the procedure (p=0.001). The mean pre- and post-procedural pulmonary arterial pressure was 44±7.1 mmHg and 36.3±4.5 mmHg, respectively, indicating a statistically significant difference (p=0.001). Of the patients, 93.7% were free from post-procedural complications. Conclusion The EkoSonic™ endovascular system improved right ventricular dysfunction, decreased pulmonary arterial pressure, and improved oxygenation in patients with intermediate-high-risk pulmonary embolism without increasing the risk for bleeding.
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Abou Ali AN, Saadeddin Z, Chaer RA, Avgerinos ED. Catheter directed interventions for pulmonary embolism: current status and future prospects. Expert Rev Med Devices 2020; 17:103-110. [DOI: 10.1080/17434440.2020.1714432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Adham N. Abou Ali
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rabih A. Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Efthymios D. Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Wu J, Chen H, Yu Y, Peng L, Li J, Liang H, Ba M, Ruan H, Hong C. Feasibility of ultrasound-assisted catheter-directed thrombolysis for submassive pulmonary embolism: A meta-analysis of case series. CLINICAL RESPIRATORY JOURNAL 2020; 14:430-439. [PMID: 31965717 DOI: 10.1111/crj.13155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 12/24/2019] [Accepted: 01/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND During the past few years, there has been a surge in the use of ultrasound-assisted catheter-directed thrombolysis (UACDT) for submassive pulmonary embolism (SPE). However, few studies evaluated the feasibility of UACDT for SPE. PURPOSE To evaluate the feasibility of UACDT in treating SPE. METHODS A comprehensive search of online databases was performed. Search terms UACDT in SPE were entered into PubMed, Embase, Scopus and the Cochrane Library to identify related articles published until October 2018. A quality assessment and data extraction were performed by two researchers. Meta-analysis was performed using R statistical software. RESULTS Twelve studies with 485 patients were included in this meta-analysis. The pooled right ventricular/left ventricular ratio decrease and pulmonary artery systolic pressure drop after treatment was -0.34 (95% CI: -0.43, -0.25) and -15.05 (95% CI: -18.10, -12.00) mm Hg, respectively. The pooled major bleeding rate was 1.0% (95% CI: 0.0%, 3.0%), and the in-hospital mortality was 0.0% (95% CI: 0.0%, 1.0%). CONCLUSION This up to data meta-analysis confirms that UACDT is a feasible treatment for SPE.
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Affiliation(s)
- Jiayan Wu
- First Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Haiming Chen
- First Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Yongqin Yu
- First Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Lingsheng Peng
- First Clinical School of Guangzhou Medical University, Guangzhou, China
| | - Jieying Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hengrui Liang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Manqing Ba
- Department of Biochemistry and Chemistry, The University of Arizona, Tucson, AZ, USA
| | - Honglian Ruan
- School of Public Health, Guangzhou Medical University, Guangzhou, China
| | - Cheng Hong
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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17
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Guliani S, Das Gupta J, Osofsky R, Marek J, Rana MA, Marinaro J. Protocolized use of catheter-directed thrombolysis and echocardiography is highly effective in reversing acute right heart dysfunction in severe submassive pulmonary embolism patients. Perfusion 2020; 35:641-648. [PMID: 31948384 DOI: 10.1177/0267659119896891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy of protocolized use of catheter-directed thrombolysis and echocardiography in submassive pulmonary embolism patients. METHODS A retrospective study at a single institution of 28 patients that presented with submassive pulmonary embolism from July 2016 to September 2019 was performed. All patients were diagnosed using chest computed tomography demonstrating a pulmonary embolism and abnormal right ventricular to left ventricular ratio. Patients with severe right heart dysfunction (right ventricular to left ventricular ratio ⩾1.4) were protocolized to receive catheter-directed thrombolysis via EkoSonic catheters (EKOS Corporation, Bothell, WA, United States). Transthoracic echocardiogram was performed after 24 hours to assess right ventricular function and determine the need to continue thrombolysis. Patients after discharge then received follow-up echocardiograms at 6 weeks to determine new post-treatment baseline. RESULTS The mean patient age was 54.6 years, mean body mass index was 35.0, and mean right ventricular to left ventricular ratio on admission computed tomography imaging was 1.70. Interval mean right ventricular to left ventricular ratio on echocardiography during thrombolysis therapy was 1.01 (p < 0.00001). Patients were tachycardic on admission (mean heart rate 102.2 beats per minute) with improvement by completion of thrombolysis (mean heart rate 72.9 beats per minute) (p < 0.00001). There was a 0% incidence of periprocedural complications. Overall 30-day complication rate was 7.1% (n = 1 arrhythmia, n = 1 delayed intracranial hemorrhage). At 6-week follow-up, 91% of the patients who received echocardiography had normal right ventricular function. CONCLUSION This retrospective study demonstrates the effectiveness of protocolized use of catheter-directed thrombolysis and echocardiography in reversing severe right heart dysfunction in submassive pulmonary embolism patients.
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Affiliation(s)
- Sundeep Guliani
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA.,Division of Vascular Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA.,Department of Critical Care, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Jaideep Das Gupta
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Robin Osofsky
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - John Marek
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA.,Division of Vascular Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Muhammad Ali Rana
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA.,Division of Vascular Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Jon Marinaro
- Department of Critical Care, School of Medicine, University of New Mexico, Albuquerque, NM, USA
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Nursing Care Practices for Patients With Pulmonary Embolism Undergoing Treatment With Ultrasound-Assisted Thrombolysis: An Integrative Review. J Cardiovasc Nurs 2019; 35:386-399. [PMID: 31851147 DOI: 10.1097/jcn.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) remains a common and life-threatening event. The use of ultrasound-assisted thrombolysis (USAT) for the delivery of thrombolytic agents to the clot has developed in the last 10 years. A search yielded no evidence-based practice guidelines for the nursing care of the patient with PE during and post USAT treatment and specifically when using the EKOS machine. OBJECTIVE The objective of this integrative review was to explore the literature and web for any information on the use of USAT for adults with PE both during and post treatment. Our goal was to examine nurse-specific practices to develop appropriate protocols. METHODS We conducted a search of PubMed, Web of Science, EBSCOhost, CINAHL, Google Scholar, and Google for any guidelines, observational studies, or experimental studies using USAT for PE in adults. Nurse authors independently reviewed the articles using a standardized data coding form. Information abstracted included sample and setting characteristics, access characteristics, medication, sheath removal, compression, and bleeding events. RESULTS Twenty-two articles, published in 2008-2019, met the eligibility criteria. Most studies were small retrospective studies at single sites. Variation existed on the clinician, the clinical area for placement, the amount and duration of delivery of medication, and where care was provided during the infusion. Few studies noted sheath removal or compression procedures. Fifteen studies reported 1 fatal, 12 major, 4 moderate, and 36 minor bleeding events at the catheter insertion sites. CONCLUSION There is lack of sufficient information for the development of nursing practice guidelines for this new technology.
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Hooks B, Sharma V, Taylor G, Wadhwani S, Ehtesham M. Outcome Measures for Acute Submassive Pulmonary Embolisms at a Community-Based Hospital Using Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis. Vasc Endovascular Surg 2019; 54:135-140. [PMID: 31769352 DOI: 10.1177/1538574419885275] [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: 11/16/2022]
Abstract
PURPOSE Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis (USAT) appears to provide promising results for the management of acute submassive pulmonary embolisms (ASMPEs) at tertiary care centers. This study assessed outcome measures at a community-based hospital systems and compared results to known studies. MATERIALS AND METHODS This is a single-center, retrospective study assessing clinical outcomes of the EkoSonic Endovascular System intervention for ASMPEs performed by three surgical 3 subspecialties (interventional radiology, interventional cardiology, and vascular surgery) part of a pulmonary embolism response team (PERT). We reviewed 146 PERT activations from June 2013 to December 2017. Eighty-three patients with ASMPEs underwent USAT. RESULTS Our study showed greater differences (P = .01) between baseline and follow-up pulmonary artery systolic pressures (20.9 ± 9.8 mm Hg [n = 14]) compared to the ULTIMA study (12.3 ± 10 mm Hg [n = 30]). Our length-of-stay measures were shorter (6.1 ± 5.1 [n = 83]; P = .0001) compared to the SEATTLE II study (8.8 ± 5.0 [n = 150]). Preprocedure transthoracic echocardiograms (TTEs) were performed for 54 (65%) of 83 patients. Postprocedure TTEs at 48 hours was performed for 52 (62%) of 83 patients. Use of TTEs before and after intervention did not change outcomes. Intracranial hemorrhage was not observed in our patient population. There was no difference in outcomes between the three subspecialties in our study. CONCLUSIONS Use of USAT in a community-based hospital PERT has similar outcomes to tertiary care centers. Furthermore, similar outcomes were observed between the three subspecialties suggesting development of a comprehensive care team for management of ASMPEs.
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Affiliation(s)
- Brandon Hooks
- Division of Pulmonary and Critical Care Medicine, Ascension Providence-Providence Park Hospital, Novi, MI, USA
| | - Vinay Sharma
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Gavin Taylor
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Sumeet Wadhwani
- Department of Internal Medicine, Ascension Providence-Providence Park Hospital, Novi, MI, USA
| | - Muhammad Ehtesham
- Division of Pulmonary and Critical Care Medicine, Ascension Providence-Providence Park Hospital, Novi, MI, USA
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Chopard R, Ecarnot F, Meneveau N. Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence. Eur Heart J Suppl 2019; 21:I23-I30. [PMID: 31777454 PMCID: PMC6868391 DOI: 10.1093/eurheartj/suz224] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, EA3920, University Hospital Besançon, Boulevard Fleming, 25030 Besançon, France
| | - Fiona Ecarnot
- Department of Cardiology, EA3920, University Hospital Besançon, Boulevard Fleming, 25030 Besançon, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Besançon, Boulevard Fleming, 25030 Besançon, France
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Pei DT, Liu J, Yaqoob M, Ahmad W, Bandeali SS, Hamzeh IR, Virani SS, Hira RS, Lakkis NM, Alam M. Meta-Analysis of Catheter Directed Ultrasound-Assisted Thrombolysis in Pulmonary Embolism. Am J Cardiol 2019; 124:1470-1477. [PMID: 31492420 DOI: 10.1016/j.amjcard.2019.07.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/30/2022]
Abstract
Ultrasound-assisted catheter directed thrombolysis (USAT) has been shown to improve hemodynamic function and reduce bleeding complications in patients with acute massive or submassive pulmonary embolism. We performed a meta-analysis to better evaluate the efficacy and safety of USAT. We conducted an extensive literature search in PUBMED, MEDLINE, and EMBASE databases from January 1, 2008 to December 31, 2018. Efficacy outcomes of interest were pulmonary artery systolic pressure, mean pulmonary pressure, ratio of right ventricular to left ventricular diameter, cardiac index, tricuspid annular plane systolic excursion, Miller Index Score, and Qanadli Score. Safety outcomes were in-hospital mortality, long-term mortality, major and minor bleeding complications, and recurrent pulmonary embolism. Meta-analysis was performed using Cochrane Collaboration Review Manager (version 5.1). Effect size was estimated using random effects model, with 95% confidence intervals (CIs). Twenty-eight studies (n = 2,135) met inclusion criteria. Compared with pretreatment parameters, post-USAT was associated with a reduction in the mean Miller Index Score and Qanadli Score by 10.55 (95% CI -12.98 to -8.12) and 15.64 (95% CI -19.08 to -12.20), respectively. Cardiac index and tricuspid annular plane systolic excursion improved by 0.68 L/m2 (95% CI 0.49 to 0.87) and 3.68 mm (95% CI 2.43 to 4.93), respectively. Pulmonary artery systolic pressure and mean pulmonary pressure after therapy were reduced by a mean difference of 16.69 mm Hg (95% CI -19.73 to -13.65) and 12.13 mm Hg (95% CI -14.67 to -9.59) respectively. The right ventricular to left ventricular diameter dimension ratio decreased by 0.35 (95% CI -0.40 to -0.30) after therapy. In-hospital mortality in patients who underwent USAT was 2.9%, and total long-term mortality was 4.1%. Major and minor bleeding complications were seen in in 5.4% and 6.0% of patients, respectively. Recurrent events occurred in 0.2% of patients after USAT. In conclusion, USAT is a safe and effective procedure associated with significant hemodynamic and clinical improvement in patients with massive and submassive pulmonary embolism.
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Affiliation(s)
- Dorothy T Pei
- Department of Medicine, Baylor College of Medicine, Houston, Texas.
| | - Jing Liu
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Maidah Yaqoob
- Department of Pulmonary, Critical Care Medicine, and Sleep and Allergy, University of Illinois College of Medicine, Chicago, Illinois
| | - Waqas Ahmad
- Nishtar Medical University, Multan, Pakistan
| | | | - Ihab R Hamzeh
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Salim S Virani
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ravi S Hira
- Department of Medicine, Section of Cardiology, University of Washington, Seattle, Washington
| | - Nasser M Lakkis
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mahboob Alam
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
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Rawal A, Ardeshna D, Hesterberg K, Cave B, Ibebuogu UN, Khouzam RN. Is there an optimal "door to cath time" in the treatment of acute pulmonary embolism with catheter-directed thrombolysis? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:419. [PMID: 31660318 DOI: 10.21037/atm.2019.07.89] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ultrasound assisted catheter-directed thrombolysis (UACT) is a relatively novel approach to treating acute pulmonary embolism (PE). It is an alternative to systemic thrombolysis with good success rates and low reported in-hospital mortality, and low rates of procedure-related major and minor bleeding. Since UACT received FDA approval for the treatment of PE in 2014, there is paucity of data regarding the optimal timing of initiation of the procedure after the initial diagnosis is made. We reviewed the available literature regarding UACT for acute PE and found six studies that included time to procedure. Based on our review, patients may benefit from early (<24-48 h after presentation) rather than delayed (>48 h) initiation. Early initiation of therapy has shown to improve pulmonary arterial pressures, right ventricular (RV) to left ventricular (LV) ratios, with low rates of bleeding and low post procedural and in hospital mortality. However, further studies are required to confirm these findings and establish the appropriate timeline for initiation of UACT.
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Affiliation(s)
- Aranyak Rawal
- Department of Internal Medicine-Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Devarshi Ardeshna
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kirstin Hesterberg
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Uzoma N Ibebuogu
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rami N Khouzam
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Das Gupta J, Marek J, Rana MA, Guliani S. Same-Day ICU Discharge in Selected Patients With Severe Submassive Pulmonary Embolism Treated With Catheter-Directed Thrombolysis. Vasc Endovascular Surg 2019; 54:58-64. [DOI: 10.1177/1538574419872047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart dysfunction and symptomatic improvement received bedside removal of catheters. The mean patient age was 50.6 years and body mass index was 33.6. Mean RV/LV ratio on admission via CT imaging was 1.56, with a mean troponin of 0.44. Interval mean RV/LV ratio on echocardiography after thrombolysis therapy was 0.91. There was a 0% incidence of periprocedural complications. One (20%) patient out of 5 had an emergency department visit 10 days postdischarge for acute shortness of breath, with workup revealing no evidence of recurrent PE. No patient required hospital readmission within 30 days. At the 6-week follow-up, all patients had continued normal right ventricular function noted on echocardiography. This case series demonstrates that for a select population of patients with severe submassive PE, the use of CDT and echocardiography monitoring can facilitate same-day discharge from the ICU.
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Affiliation(s)
- Jaideep Das Gupta
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - John Marek
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Muhammad Ali Rana
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Sundeep Guliani
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Abstract
Thrombolytic treatment accelerates the dissolution of thrombus in acute pulmonary thromboembolism (PTE) and is potentially a lifesaving treatment. High-risk PTE is the clearest indication for this therapy, and its use in intermediate-risk cases is still controversial. A PTE response team may enable a rapid and effective determination of risk and treatment in these controversial clinical cases. Approved thrombolytic agents for the PTE treatment are streptokinase, urokinase, and alteplase. Currently, the most widely used agent is alteplase. It has a short infusion time (2 h) and a rapid effect. Newer, unapproved agents for the PTE treatment are tenecteplase and reteplase. The active resolution of thrombus via thrombolytic agents improves rapidly pulmonary perfusion, hemodynamic defect, gas exchange, and right ventricular dysfunction. However, it is important to determine appropriate candidates carefully, to prevent hemorrhage, which is the most important side effect of these drugs. Catheter-directed thrombolysis seems to be an alternative in patients not eligible for systemic thrombolytic therapy.
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Affiliation(s)
- Elif Yilmazel Ucar
- Department of Pulmonary Diseases, Ataturk University School of Medicine, Erzurum, Turkey
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25
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Abstract
Intermediate-risk pulmonary embolism is common and carries a risk of progression to hemodynamic collapse and death. Catheter-directed thrombolysis is an increasingly used treatment option, based largely on the assumptions that it is more efficacious than anticoagulation alone and safer than systemic thrombolysis. In this review, we critically analyze the published data regarding catheter-directed thrombolysis for the treatment of intermediate-risk pulmonary embolism. Catheter-directed thrombolysis reduces right heart strain and lowers pulmonary artery pressures more quickly than anticoagulation alone. The mortality for patients with intermediate-risk pulmonary embolism treated with catheter-directed thrombolysis is low, between 0% and 4%. However, similarly low mortality is seen with anticoagulation alone. Catheter-directed thrombolysis appears to be safer than systemic thrombolysis, and procedural complications are uncommon. Bleeding risk appears to be slightly higher than with anticoagulation alone. Randomized, controlled trials are needed to compare the efficacy and safety of catheter-directed thrombolysis versus anticoagulation for intermediate-risk pulmonary embolism. There is no evidence that catheter-directed thrombolysis decreases the incidence of chronic thromboembolic pulmonary hypertension. There is no evidence from clinical studies that ultrasound-assisted thrombolysis is more effective or safer than standard catheter-directed thrombolysis.
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26
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de Winter MA, Hart EA, van den Heuvel DAF, Moelker A, Lely RJ, Kaasjager KAH, Stella PR, Chamuleau SAJ, Kraaijeveld AO, Nijkeuter M. Local Ultrasound-Facilitated Thrombolysis in High-Risk Pulmonary Embolism: First Dutch Experience. Cardiovasc Intervent Radiol 2019; 42:962-969. [PMID: 30863964 PMCID: PMC6542777 DOI: 10.1007/s00270-019-02200-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/07/2019] [Indexed: 01/12/2023]
Abstract
Purpose To provide insight into the current use and results of ultrasound-facilitated catheter-directed thrombolysis (USAT) in patients with high-risk pulmonary embolism (PE). Introduction Systemic thrombolysis is an effective treatment for hemodynamically unstable, high-risk PE, but is associated with bleeding complications. USAT is thought to reduce bleeding and is therefore advocated in patients with high-risk PE and contraindications for systemic thrombolysis. Methods We conducted a retrospective cohort study of all patients who underwent USAT for high-risk PE in the Netherlands from 2010 to 2017. Characteristics and outcomes were analyzed. Primary outcomes were major (including intracranial and fatal) bleeding and all-cause mortality after 1 month. Secondary outcomes were all-cause mortality and recurrent venous thromboembolism within 3 months. Results 33 patients underwent USAT for high-risk PE. Major bleeding occurred in 12 patients (36%, 95% CI 22–53), including 1 intracranial and 3 fatal bleeding. All-cause mortality after 1 month was 48% (16/33, 95% CI 31–66). All-cause mortality after 3 months was 50% (16/32, 95% CI 34–66), recurrent venous thromboembolism occurred in 1 patient (1/32, 3%, 95% CI 1–16). Conclusions This study was the first to describe characteristics and outcomes after USAT in a study population of patients with high-risk PE only, an understudied population. Although USAT is considered a relatively safe treatment option, our results illustrate that at least caution is needed in critically ill patients with high-risk PE. Further research in patients with high-risk PE is warranted to guide patient selection.
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Affiliation(s)
- Maria A de Winter
- Department of Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands.
| | - Einar A Hart
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Daniel A F van den Heuvel
- Department of Interventional Radiology, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein, The Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center Rotterdam, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - Rutger J Lely
- Department of Interventional Radiology, VU University Medical Center, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Pieter R Stella
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Adriaan O Kraaijeveld
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
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Visco E, Adamo M, Locantore E, Fiorina C, Chizzola G, Branca L, Abbenante A, Castiello A, Metra M, Curello S, Ettori F. EkoSonic Endovascular System for patients with acute pulmonary embolism and contraindication to systemic fibrinolysis. J Cardiovasc Med (Hagerstown) 2019; 20:131-136. [DOI: 10.2459/jcm.0000000000000751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kaymaz C, Akbal OY, Hakgor A, Tokgoz HC, Karagoz A, Tanboga IH, Tanyeri S, Keskin B, Turkday S, Demir D, Dogan C, Bayram Z, Acar RD, Guvendi B, Ozdemir N, Tapson VF, Konstantinides S. A five-year, single-centre experience on ultrasound-assisted, catheter-directed thrombolysis in patients with pulmonary embolism at high risk and intermediate to high risk. EUROINTERVENTION 2018; 14:1136-1143. [DOI: 10.4244/eij-d-18-00371] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Avgerinos ED, Saadeddin Z, Abou Ali AN, Fish L, Toma C, Chaer M, Rivera-Lebron BN, Chaer RA. A meta-analysis of outcomes of catheter-directed thrombolysis for high- and intermediate-risk pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2018; 6:530-540. [DOI: 10.1016/j.jvsv.2018.03.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/02/2018] [Indexed: 02/06/2023]
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Kolkailah AA, Hirji S, Piazza G, Ejiofor JI, Ramirez Del Val F, Lee J, McGurk S, Aranki SF, Shekar PS, Kaneko T. Surgical pulmonary embolectomy and catheter-directed thrombolysis for treatment of submassive pulmonary embolism. J Card Surg 2018; 33:252-259. [PMID: 29659045 DOI: 10.1111/jocs.13576] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute pulmonary embolism (PE) with preserved hemodynamics but right ventricular dysfunction, classified as submassive PE, carries a high risk of mortality. We report the results for patients who did not qualify for medical therapy and required treatment of submassive PE with surgical pulmonary embolectomy and catheter-directed thrombolysis (CDT). METHODS Between October 1999 and May 2015, 133 submassive PE patients underwent treatment with pulmonary embolectomy (71) and CDT (62). A multidisciplinary PE response team helped to determine the most appropriate treatment strategy on a case-by-case basis. The EkoSonic ultrasound-facilitated thrombolysis system (EKOS) was used for CDT, which was introduced in 2010. RESULTS The mean age of submassive PE patients was 57.3 years, which included 36.8% females. PE risk factors included previous deep venous thrombosis (46.6%), immobility (36.1%), recent surgery (30.8%), and cancer (22.6%), P < 0.05. The most common indication for advanced treatment was right ventricular strain (42.9%), P = 0.03. The frequency of surgical pulmonary embolectomy remained stable even after incorporating the EKOS procedure into our treatment algorithm, with statistically similar operative mortality. Bleeding was observed in six CDT patients and one pulmonary embolectomy patient (P < 0.05). Follow-up echocardiography was available for 61% of the overall cohort, of whom 76.5% had no residual moderate or severe right ventricular dysfunction. CONCLUSIONS Pulmonary embolectomy and CDT are important contemporary advanced treatment options for selected high-risk patients with submassive PE, who do not qualify for medical therapy.
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Affiliation(s)
- Ahmed A Kolkailah
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julius I Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fernando Ramirez Del Val
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jiyae Lee
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sary F Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Prem S Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Avgerinos ED, Mohapatra A, Rivera-Lebron B, Toma C, Kabrhel C, Fish L, Lacomis J, Ocak I, Chaer RA. Design and rationale of a randomized trial comparing standard versus ultrasound-assisted thrombolysis for submassive pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2018; 6:126-132. [PMID: 29248101 PMCID: PMC6394224 DOI: 10.1016/j.jvsv.2017.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/18/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Catheter-directed interventions for the treatment of patients with submassive pulmonary embolism (sPE) have shown promise in rapidly improving right-sided heart strain and preventing decompensation to massive pulmonary embolism. Among various catheter interventions, ultrasound-assisted thrombolysis (USAT) has attracted interest as potentially having more efficient lytic effect that could achieve thrombolysis faster and with a reduced lytic dose. However, based on clinical evidence, it is unclear whether USAT is superior to standard catheter-directed thrombolysis (SCDT). We herein describe the study design of the Standard vs UltrasouNd-assiSted CathEter Thrombolysis for Submassive Pulmonary Embolism (SUNSET sPE) trial, an ongoing randomized clinical trial designed to address this question. METHODS Adults with sPE presenting or referred to our institution are considered for enrollment in the trial. At the discretion of the treatment team, all patients undergo a catheter-directed intervention plus concomitant therapeutic anticoagulation. Participants are randomized 1:1 to a USAT catheter or an SCDT catheter. Study assessors are blinded to treatment group. The primary outcome is clearance of pulmonary thrombus burden, assessed by postprocedure computed tomography angiography. Secondary outcomes include resolution of right ventricular strain by echocardiography; improvement in pulmonary artery pressures; and 3- and 12-month improvement in echocardiographic, functional capacity, and quality of life measures. The study is powered to detect a 50% improvement in pulmonary artery thrombus clearance. Our enrollment target is 40 patients per treatment arm. CONCLUSIONS SUNSET sPE is an ongoing randomized, head-to-head, single-blinded clinical trial with the goal of assessing whether USAT results in superior thrombus clearance compared with SCDT in patients with sPE. We expect the results of our study to inform future guidelines on choice of thrombolysis modality in this population of challenging patients.
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Affiliation(s)
- Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Abhisekh Mohapatra
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Belinda Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Catalin Toma
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Larry Fish
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joan Lacomis
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Iclal Ocak
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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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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Comparison of Ultrasound-Accelerated versus Pigtail Catheter-Directed Thrombolysis for the Treatment of Acute Massive and Submassive Pulmonary Embolism. J Vasc Interv Radiol 2017; 28:1339-1347. [PMID: 28827014 DOI: 10.1016/j.jvir.2017.07.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To compare the technical and clinical effectiveness of ultrasound-accelerated endovascular thrombolysis (USAT) versus pigtail catheter-directed thrombolysis (PCDT) for the treatment of acute pulmonary embolism (PE). MATERIALS AND METHODS A single-center retrospective study of patients treated with USAT or PCDT for acute massive or submassive PE between January 2010 and December 2016 was performed by reviewing electronic medical records. Sixty treatments were reviewed (mean patient age, 56.7 y ± 14.6), including 52 cases of submassive PE (21 treated with USAT, 31 with PCDT) and 8 cases of massive PE (3 treated with USAT, 5 with PCDT). Endpoints included pulmonary artery pressure (PAP), Miller PE severity index, tissue plasminogen activator (TPA) dose, infusion duration, procedural variables, and complications. RESULTS Demographics, PE severity, and right:left ventricular diameter ratios were similar between groups. USAT and PCDT significantly reduced mean PAP (reductions of 7.4 mm Hg [P = .002] and 8.2 mm Hg [P < .001], respectively) and Miller index scores (reductions of 45.8% [P < .001] and 53% [P < .001], respectively) with similar effectiveness (P = .47 and P = .15, respectively). Procedure (P < .001) and fluoroscopy (P = .001) times were significantly longer in the USAT group. The USAT group underwent fewer sessions (2.2 ± 0.6 vs 2.4 ± 0.6; P = .17) with shorter infusion times (23.9 h ± 8.8 vs 30.4 h ± 12.6; P = .065) and a lower total dose of TPA (27.1 mg ± 11.3 vs 30.4 mg ± 12.6; P = .075) compared with the PCDT group, but the differences were not significant. Complications (P = .07) and 30-day mortality rates (P = .56) were not significantly different between groups. CONCLUSIONS USAT and PCDT demonstrated comparable effectiveness and safety in the treatment of patients with acute PE.
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Mangi MA, Rehman H, Bansal V, Zuberi O. Ultrasound Assisted Catheter-Directed Thrombolysis of Acute Pulmonary Embolism: A Review of Current Literature. Cureus 2017; 9:e1492. [PMID: 28944131 PMCID: PMC5605122 DOI: 10.7759/cureus.1492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Pulmonary embolism continues as a very common and also presumably life-threatening disorder. For affected individuals with intermediate- as well as high-risk pulmonary embolism, catheter-based revascularization procedures have developed a possible substitute for systemic thrombolysis or for surgical embolectomy. Ultrasound-assisted catheter-directed thrombolysis is an innovative catheter-based approach; which is the main purpose of the present review article. Ultrasound-assisted catheter-directed thrombolysis is much more efficacious in reversing right ventricular dysfunction as well as dilatation in comparison to anticoagulation alone in individuals at intermediate risk. However, a direct comparison of ultrasound-assisted thrombolysis with systemic thrombolysis or surgical thrombectomy is not available. Ultrasound-assisted thrombolysis with early intrapulmonary thrombolytic bolus could also be successful in high-risk patients, but unfortunately, data from randomized trials is limited. This review article recapitulates existing information on ultrasound-assisted thrombolysis for acute pulmonary embolism.
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Affiliation(s)
| | - Hiba Rehman
- GME Internal Medicine, Orange Park Medical Center
| | - Vikas Bansal
- Critical Care Medicine, Mayo Clinic Jacksonville, Fl
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35
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Bloomer TL, El-Hayek GE, McDaniel MC, Sandvall BC, Liberman HA, Devireddy CM, Kumar G, Fong PP, Jaber WA. Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis. Catheter Cardiovasc Interv 2017; 89:754-760. [PMID: 28145042 DOI: 10.1002/ccd.26900] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/11/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE). BACKGROUND The use of CDT for the treatment of acute submassive and massive PE is increasing in frequency. However, its safety and efficacy have not been well elucidated. METHODS This study is made of two parts: one is a two-center registry of acute PE patients treated with CDT. The safety outcome evaluated was any major complication including fatal, intracranial (ICH), intraocular, or retroperitoneal hemorrhage or any overt bleeding requiring transfusion or surgical repair. The efficacy outcome was acute change in invasive pulmonary artery systolic pressure (PASP). The second part is a meta-analysis of all contemporary studies that used CDT for PE. Reported outcomes are the same as in the registry, with the addition of right ventricular to left ventricular (RV/LV) ratio change. RESULTS In the registry, 137 patients were included (age 59 ± 15, 50% male, 88% submassive PE). ICH occurred in two patients and major complications in 13 (9.4%). PASP decreased post procedure by 19 ± 15 mm Hg (95% CI 16-23). In the meta-analysis, 16 studies were included with 860 patients. Rate of ICH was 0.35% and the major complication rate was 4.65%, most requiring transfusion only. In-hospital mortality was 12.9% in the massive and 0.74% in the submassive group. All studies showed improvement in PASP and/or RV/LV ratio post CDT. CONCLUSIONS CDT is associated with a low major complication rate. Randomized studies are needed to evaluate its efficacy relative to anticoagulation alone. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Tyler L Bloomer
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Georges E El-Hayek
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael C McDaniel
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Breck C Sandvall
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Henry A Liberman
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Chandan M Devireddy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Gautam Kumar
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Pete P Fong
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wissam A Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Fuller TJ, Paprzycki CM, Zubair MH, Hussain LR, Kuhn BA, Recht MH, Muck PE. Initial Experiences with Endovascular Management of Submassive Pulmonary Embolism: Is It Safe? Ann Vasc Surg 2017; 38:158-163. [DOI: 10.1016/j.avsg.2016.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
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Bajaj NS, Kalra R, Arora P, Ather S, Guichard JL, Lancaster WJ, Patel N, Raman F, Arora G, Al Solaiman F, Clark DT, Dell'Italia LJ, Leesar MA, Davies JE, McGiffin DC, Ahmed MI. Catheter-directed treatment for acute pulmonary embolism: Systematic review and single-arm meta-analyses. Int J Cardiol 2016; 225:128-139. [DOI: 10.1016/j.ijcard.2016.09.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/05/2016] [Accepted: 09/15/2016] [Indexed: 12/19/2022]
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Ricci DR, Marotta TR, Riina HA, Wan M, De Vries J. A training paradigm to enhance performance and safe use of an innovative neuroendovascular device. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2016; 4:33248. [PMID: 27867466 PMCID: PMC5105320 DOI: 10.3402/jmahp.v4.33248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/12/2016] [Accepted: 10/12/2016] [Indexed: 06/06/2023]
Abstract
Training has been important to facilitate the safe use of new devices designed to repair vascular structures. This paper outlines the generic elements of a training program for vascular devices and uses as an example the actual training requirements for a novel device developed for the treatment of bifurcation intracranial aneurysms. Critical elements of the program include awareness of the clinical problem, technical features of device, case selection, and use of a simulator. Formal proctoring, evaluation of the training, and recording the clinical outcomes complement these elements. Interventional physicians should embrace the merits of a training module to improve the user experience, and vendors, physicians, and patients alike should be aligned in the goal of device training to improve its success rate and minimize complications of the procedure.
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Affiliation(s)
- Donald R. Ricci
- Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
- Evasc Medical Systems Corporation, Vancouver, BC, Canada
| | - Thomas R. Marotta
- Diagnostic and Therapeutic Neuroradiology, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Howard A. Riina
- Department of Neurosurgery, NYU School of Medicine, NYU Langone Medical Center, New York, NY, USA
| | - Martina Wan
- Evasc Medical Systems Corporation, Vancouver, BC, Canada
| | - Joost De Vries
- Department of Neurosurgery, Radboud University Nijmegen, Nijmegen, The Netherlands
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Abstract
Venous thromboembolism (VTE), which constitutes pulmonary embolism and deep vein thrombosis, is a common disorder associated with significant morbidity and mortality. Landmark trials have shown that direct oral anticoagulants (DOACs) are as effective as conventional anticoagulation with vitamin K antagonists (VKA) in prevention of VTE recurrence and associated with less bleeding. This has paved the way for the recently published guidelines to change their recommendations in favor of DOACs in acute and long-term treatment of VTE in patients without cancer. The recommended treatment of VTE in cancer patients remains low-molecular-weight heparin. The initial management of pulmonary embolism (PE) should be directed based on established risk stratification scores. Thrombolysis is an available option for patients with hemodynamically significant PE. Recent data suggests that low-risk patients with acute PE can safely be treated as outpatients if home circumstances are adequate. There is lack of support for use of inferior vena cava filters in patients on anticoagulation. This review describes the acute, long-term, and extended treatment of VTE and recent evidence on the management of sub-segmental PE.
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Affiliation(s)
- Siavash Piran
- Department of Medicine, Division of Hematology and Thromboembolism, and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON L8L 2X2 Canada
| | - Sam Schulman
- Department of Medicine, Division of Hematology and Thromboembolism, and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON L8L 2X2 Canada
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Teleb M, Porres-Aguilar M, Rivera-Lebron B, Ngamdu KS, Botrus G, Anaya-Ayala JE, Mukherjee D. Ultrasound-Assisted Catheter-Directed Thrombolysis: A Novel and Promising Endovascular Therapeutic Modality for Intermediate-Risk Pulmonary Embolism. Angiology 2016; 68:494-501. [PMID: 27609936 DOI: 10.1177/0003319716665718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intermediate-risk pulmonary embolism (PE), also known as submassive PE, occurs in a substantial group of patients and carries a significant mortality risk. With adequate risk stratification, catheter-directed techniques could be used as a therapeutic approach in the intermediate-risk PE. Ultrasound-assisted catheter-directed thrombolysis (UCDT) represents a novel endovascular technique with good clinical and safety outcomes. Ultrasound-assisted catheter-directed thrombolysis can achieve reduction in the thrombus burden and improvement of pulmonary hemodynamics and right ventricular (RV) dysfunction and/or dilatation, without major procedure-related complications, major bleeding, or hemorrhagic strokes. This narrative review will focus on the major studies involving the efficacy and safety of UCDT in the intermediate-risk PE population. Prospective, randomized clinical trials with long-term follow-up and a large sample size are needed for further evaluation of mortality benefit and to further define which subgroup of patients may benefit from this novel endovascular technique.
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Affiliation(s)
- Mohamed Teleb
- 1 Department of General Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA.,2 Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Mateo Porres-Aguilar
- 1 Department of General Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Belinda Rivera-Lebron
- 3 Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kyari Sumayin Ngamdu
- 1 Department of General Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Gehan Botrus
- 1 Department of General Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Javier E Anaya-Ayala
- 4 Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutricion "Salvador Zubirán, México City, México
| | - Debabrata Mukherjee
- 2 Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center, El Paso, Texas, USA
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Abou Ali AN, Liang NL, Chaer RA, Avgerinos ED. Catheter Interventions for Pulmonary Embolism: Are They Really that Safe? Am J Cardiol 2016; 118:307-8. [PMID: 27108339 DOI: 10.1016/j.amjcard.2016.03.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/18/2016] [Indexed: 11/24/2022]
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Ouriel K, Ouriel RL, Lim YJ, Piazza G, Goldhaber SZ. Computed tomography angiography with pulmonary artery thrombus burden and right-to-left ventricular diameter ratio after pulmonary embolism. Vascular 2016; 25:54-62. [DOI: 10.1177/1708538116645056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose Computed tomography angiography is used for quantifying the significance of pulmonary embolism, but its reliability has not been well defined. Methods The study cohort comprised 10 patients randomly selected from a 150-patient prospective trial of ultrasound-facilitated fibrinolysis for acute pulmonary embolism. Four reviewers independently evaluated the right-to-left ventricular diameter ratios using the standard multiplanar reformatted technique and a simplified (axial) method, and thrombus burden with the standard modified Miller score and a new, refined Miller scoring system. Results The intraclass correlation coefficient for intra-observer variability was .949 and .970 for the multiplanar reformatted and axial methods for estimating right-to-left ventricular ratios, respectively. Inter-observer agreement was high and similar for the two methods, with intraclass correlation coefficient of .969 and .976. The modified Miller score had good intra-observer agreement (intraclass correlation coefficient .820) and was similar to the refined Miller method (intraclass correlation coefficient .883) for estimating thrombus burden. Inter-observer agreement was also comparable between the techniques, with intraclass correlation coefficient of .829 and .914 for the modified Miller and refined Miller methods. Conclusions The reliability of computed tomography angiography for pulmonary embolism was excellent for the axial and multiplanar reformatted methods for quantifying the right-to-left ventricular ratio and for the modified Miller and refined Miller scores for quantifying of pulmonary artery thrombus burden.
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Affiliation(s)
| | | | | | - Gregory Piazza
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Avgerinos ED, Liang NL, El-Shazly OM, Toma C, Singh MJ, Makaroun MS, Chaer RA. Improved early right ventricular function recovery but increased complications with catheter-directed interventions compared with anticoagulation alone for submassive pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2016; 4:268-75. [PMID: 27318043 PMCID: PMC7151648 DOI: 10.1016/j.jvsv.2015.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/20/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the short-term and midterm outcomes of catheter-directed intervention (CDI) compared with anticoagulation (AC) alone in patients with submassive pulmonary embolism (sPE). METHODS This was a retrospective review of all patients treated for sPE between January 2009 and October 2014. Two groups were identified on the basis of the therapy: AC and CDI. End points included complications, mortality, and change in echocardiographic parameters. Standard statistical techniques were used. RESULTS There were 64 patients who received AC and 64 patients who received CDI (five were initially treated with AC but did not improve or worsened; six received ≤8 mg of tissue plasminogen activator). Most baseline characteristics, including the Pulmonary Embolism Severity Index, were similar among the AC and CDI groups. There was no difference in PE-related death (one in each group) or major bleeding events (three in the AC group, four in the CDI group), but CDIs had two additional procedural complications that required open heart surgery. CDIs showed significantly more minor bleeding events (6 vs 0; P = .028) and significantly shorter intensive care unit stay (2.7 ± 2.1 vs 5.6 ± 7.5 days; P = .04). The mean difference in right ventricular/left ventricular ratio from baseline to the first subsequent echocardiogram (within 30 days) showed a trend for higher reduction in favor of CDI (AC, 0.17 ± 0.12; CDI, 0.27 ± 0.15; P = .076). Between 3 and 8 months, significant improvement was evident within groups in all assessed right-sided heart echocardiographic parameters, but there was no difference between groups. Pulmonary hypertension (pulmonary artery pressure >40 mm Hg) was present in 7 of 15 of the AC group vs 6 of 19 of the CDI group (P = .484). During the follow-up, dyspnea or oxygen dependence, not existing before the index PE event, was recorded in 5 of 49 (10.2%) of the AC patients and 8 of 52 (15.4%) of the CDI patients (P = .556). CONCLUSIONS CDI for sPE can result in faster restoration of right ventricular function and shorter intensive care unit stay, but at the cost of a higher complication rate, with similar midterm outcomes compared with AC alone. A potential effect of CDI on mortality and pulmonary hypertension needs further investigation through larger studies.
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Affiliation(s)
- Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Omar M El-Shazly
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Catalyn Toma
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis. J Thromb Thrombolysis 2016; 42:322-8. [DOI: 10.1007/s11239-016-1370-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ultrasound Accelerated Thrombolysis in patients with acute pulmonary embolism: A systematic review and proportion meta-analysis. Int J Cardiol 2016; 211:27-30. [PMID: 26970962 DOI: 10.1016/j.ijcard.2016.02.148] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/21/2016] [Accepted: 02/28/2016] [Indexed: 11/21/2022]
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