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Vrettou CS, Dima E, Karela NR, Sigala I, Korfias S. Severe Traumatic Brain Injury and Pulmonary Embolism: Risks, Prevention, Diagnosis and Management. J Clin Med 2024; 13:4527. [PMID: 39124793 PMCID: PMC11313609 DOI: 10.3390/jcm13154527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Severe traumatic brain injury (sTBI) is a silent epidemic, causing approximately 300,000 intensive care unit (ICU) admissions annually, with a 30% mortality rate. Despite worldwide efforts to optimize the management of patients and improve outcomes, the level of evidence for the treatment of these patients remains low. The concomitant occurrence of thromboembolic events, particularly pulmonary embolism (PE), remains a challenge for intensivists due to the risks of anticoagulation to the injured brain. We performed a literature review on sTBI and concomitant PE to identify and report the most recent advances on this topic. We searched PubMed and Scopus for papers published in the last five years that included the terms "pulmonary embolism" and "traumatic brain injury" in their title or abstract. Exclusion criteria were papers referring to children, non-sTBI populations, and post-acute care. Our search revealed 75 papers, of which 38 are included in this review. The main topics covered include the prevalence of and risk factors for pulmonary embolism, the challenges of timely diagnosis in the ICU, the timing of pharmacological prophylaxis, and the treatment of diagnosed PE.
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Affiliation(s)
- Charikleia S. Vrettou
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Effrosyni Dima
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Nina Rafailia Karela
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Ioanna Sigala
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Stefanos Korfias
- Department of Neurosurgery, Evaggelismos General Hospital of Athens, 10676 Athens, Greece
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Rush B, Ziegler J, Dyck S, Dhaliwal S, Mooney O, Lother S, Celi LA, Mendelson AA. Disparities in access to and timing of interventional therapies for pulmonary embolism across the United States. J Thromb Haemost 2024; 22:1947-1955. [PMID: 38554934 DOI: 10.1016/j.jtha.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/20/2024] [Accepted: 03/15/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Interventional therapies (ITs) are an emerging treatment modality for pulmonary embolism (PE); however, the degree of racial, sex-based, and sociodemographic disparities in access and timing is unknown. OBJECTIVES To investigate barriers to access and timing of ITs for PE across the United States. METHODS A retrospective cohort study utilizing the Nationwide Inpatient Sample from 2016-2020 included adult patients with PE. The use of ITs (mechanical thrombectomy and catheter-directed thrombolysis) was identified via International Classification of Diseases 10th revision codes. Early IT was defined as procedure performed within the first 2 days after admission. RESULTS A total of 27 805 273 records from the 2016-2020 Nationwide Inpatient Sample database were examined. There were 387 514 (1.4%) patients with PE, with 14 249 (3.6%) of them having undergone IT procedures (11 115 catheter-directed thrombolysis, 2314 thrombectomy, and 780 both procedures). After multivariate adjustment, factors associated with less use of IT included Black race (odds ratio [OR], 0.90; 95% CI, 0.86-0.94; P < .01), Hispanic race (OR, 0.73; 95% CI, 0.68-0.79; P < .01), female sex (OR, 0.88; 95% CI, 0.85-0.91; P < .01), treatment in a rural hospital (OR, 0.49; 95% CI, 0.44-0.54; P < .01), and lack of private insurance (Medicare OR, 0.77; 95% CI, 0.73-0.80; P < .01; Medicaid OR, 0.65; 95% CI, 0.61-0.69; P < .01; no coverage OR, 0.87; 95% CI, 0.82-0.93; P < .01). Among the patients who received IT, 11 315 (79%) procedures were conducted within 2 days of admission and 2934 (21%) were delayed. Factors associated with delayed procedures included Black race (OR, 1.12; 95% CI, 1.01-1.26; P = .04), Hispanic race (OR, 1.52; 95% CI, 1.28-1.80; P < .01), weekend admission (OR, 1.37; 95% CI, 1.25-1.51; P < .01), Medicare coverage (OR, 1.24; 95% CI, 1.10-1.40; P < .01), and Medicaid coverage (OR, 1.29; 95% CI, 1.12-1.49; P < .01). CONCLUSION Significant racial, sex-based, and geographic barriers exist in overall access to IT for PE in the United States.
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Affiliation(s)
- Barret Rush
- Section of Critical Care Medicine, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Jennifer Ziegler
- Section of Critical Care Medicine, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephanie Dyck
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Surinder Dhaliwal
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Owen Mooney
- Section of Critical Care Medicine, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sylvain Lother
- Section of Critical Care Medicine, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leo Anthony Celi
- Harvard Medical School, Boston, Massachusetts, USA; Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Asher A Mendelson
- Section of Critical Care Medicine, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Ismayl M, Goldsweig AM. Editorial: Like a kid in a candy shop: Choosing the sweetest therapy for submassive pulmonary embolism. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:82-84. [PMID: 38245432 DOI: 10.1016/j.carrev.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/22/2024]
Affiliation(s)
- Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA, USA
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Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med 2024; 52:729-742. [PMID: 38165776 DOI: 10.1097/ccm.0000000000006162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
OBJECTIVES Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN Multicenter retrospective observational study. SETTING Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively ( p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.
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Affiliation(s)
- Roman Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - David M Tierney
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
- Department of Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Ranran Xia
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Abbey Sidebottom
- Department of Care Delivery Research, Allina Health, Minneapolis, MN
| | - Brandon M Wiley
- Department of Medicine, Los Angeles General Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ivan Khapov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Andò G, Pelliccia F, Saia F, Tarantini G, Fraccaro C, D'Ascenzo F, Zimarino M, Di Marino M, Niccoli G, Porto I, Calabrò P, Gragnano F, De Rosa S, Piccolo R, Moscarella E, Fabris E, Montone RA, Spaccarotella C, Indolfi C, Sinagra G, Perrone Filardi P. Management of high and intermediate-high risk pulmonary embolism: A position paper of the Interventional Cardiology Working Group of the Italian Society of Cardiology. Int J Cardiol 2024; 400:131694. [PMID: 38160911 DOI: 10.1016/j.ijcard.2023.131694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that remains a major global health concern. Noteworthy, patients with high- and intermediate-high-risk PE pose unique challenges because they often display clinical and hemodynamic instability, thus requiring rapid intervention to mitigate the risk of clinical deterioration and death. Importantly, recovery from PE is associated with long-term complications such as recurrences, bleeding with oral anticoagulant treatment, pulmonary hypertension, and psychological distress. Several novel strategies to improve risk factor characterization and management of patients with PE have recently been introduced. Accordingly, this position paper of the Working Group of Interventional Cardiology of the Italian Society of Cardiology deals with the landscape of high- and intermediate-high risk PE, with a focus on bridging the gap between the evolving standards of care and the current clinical practice. Specifically, the growing importance of catheter-directed therapies as part of the therapeutic armamentarium is highlighted. These interventions have been shown to be effective strategies in unstable patients since they offer, as compared with thrombolysis, faster and more effective restoration of hemodynamic stability with a consistent reduction in the risk of bleeding. Evolving standards of care underscore the need for continuous re-assessment of patient risk stratification. To this end, a multidisciplinary approach is paramount in refining selection criteria to deliver the most effective treatment to patients with unstable hemodynamics. In conclusion, the current management of unstable patients with PE should prioritize tailored treatment in a patient-oriented approach in which transcatheter therapies play a central role.
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Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "Gaetano Martino", Messina, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, "La Sapienza" University, Rome, Italy.
| | - Francesco Saia
- Department of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Turin, Italy
| | - Marco Zimarino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy; Department of Cardiology, "SS. Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | - Mario Di Marino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Italo Porto
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genoa, Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Enrico Fabris
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carmen Spaccarotella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Gianfranco Sinagra
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
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Ding JW, Jiang YA, Li P, Xie HX, Ding HS. Case Report: Thrombus aspiration and in situ thrombolysis via a Guidezilla guide extension catheter in a patient with high-risk pulmonary embolism. Front Cardiovasc Med 2024; 11:1340962. [PMID: 38606382 PMCID: PMC11007086 DOI: 10.3389/fcvm.2024.1340962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/04/2024] [Indexed: 04/13/2024] Open
Abstract
Standard catheter-directed thrombolysis (CDT) and thrombus aspiration are considered potentially promising approaches for reopening the embolism-related pulmonary artery in patients with pulmonary embolism (PE) with high thrombotic burden and deteriorating hemodynamics, especially in those for whom systemic thrombolysis is contraindicated or has failed. However, the constrained accessibility of dedicated catheters has impeded the potential benefits of standard CDT in developing countries. The Guidezilla guide extension catheter (GEC) with a larger diameter and extended length is widely used in challenging coronary anatomy. Nevertheless, there have been few reports on the application of the Guidezilla GEC as a novel option for patients with massive PE when dedicated catheters and surgical thrombectomy are not available. In this case report, we demonstrated that thrombus aspiration and in situ thrombolysis through the Guidezilla GEC are applicable to patients with PE in whom systemic thrombolysis is contraindicated, resulting in successful reperfusion and positive clinical outcomes.
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Affiliation(s)
| | | | | | | | - Huai-Sheng Ding
- Department of Cardiovascular Medicine, The Meishan People’s Hospital, Meishan, Sichuan, China
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Weekes AJ, Trautmann A, Hambright PL, Ali S, Pikus AM, Wellinsky N, Goonan KL, Bradford S, O'Connell NS. Comparison of Treatment Approaches and Subsequent Outcomes within a Pulmonary Embolism Response Team Registry. Crit Care Res Pract 2024; 2024:5590805. [PMID: 38560480 PMCID: PMC10980543 DOI: 10.1155/2024/5590805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/19/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives To characterize the association between pulmonary embolism (PE) severity and bleeding risk with treatment approaches, outcomes, and complications. Methods Secondary analysis of an 11-hospital registry of adult ED patients treated by a PE response team (August 2016-November 2022). Predictors were PE severity and bleeding risk. The primary outcome was treatment approach: anticoagulation monotherapy vs. advanced intervention (categorized as "immediate" or "delayed" based on whether the intervention was received within 12 hours of PE diagnosis or not). Secondary outcomes were death, clinical deterioration, and major bleeding. Results Of the 1832 patients, 139 (7.6%), 977 (53.3%), and 9 (0.5%) were classified as high-risk, intermediate-high, intermediate-low, and low-risk severity, respectively. There were 94 deaths (5.1%) and 218 patients (11.9%) had one or more clinical deterioration events. Advanced interventions were administered to 86 (61.9%), 195 (27.6%), and 109 (11.2%) patients with high-risk, intermediate-high, and intermediate-low severity, respectively.Major bleeding occurred in 61/1440 (4.2%) on ACm versus 169/392 (7.6%) with advanced interventions (p <0.001): bleeding withcatheter-directed thrombolysiswas 19/145 (13.1%) versus 33/154(21.4%) with systemic thrombolysis,p= 0.07. High risk was twice as strong as intermediate-high risk for association with advanced intervention (OR: 5.3 (4.2 and 6.9) vs. 1.9 (1.6 and 2.2)). High risk (OR: 56.3 (32.0 and 99.2) and intermediate-high risk (OR: 2.6 (1.7 and 4.0)) were strong predictors of clinical deterioration. Major bleeding was significantly associated with advanced interventions (OR: 5.2 (3.5 and 7.8) for immediate, 3.3 (1.8 and 6.2)) for delayed, and high-risk PE severity (OR: 3.4 (1.9 and 5.8)). Conclusions Advanced intervention use was associated with high-acuity patients experiencing death, clinical deterioration, and major bleeding with a trend towards less bleeding with catheter-directed interventions versus systemic thrombolysis.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Ariana Trautmann
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Parker L. Hambright
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Shane Ali
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Angela M. Pikus
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Nicole Wellinsky
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kelly L. Goonan
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Sarah Bradford
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Sharp ASP, Piazza G. Editorial: More than one way to skin a clot? Differing techniques for solving the problem of clinically significant pulmonary embolism. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 60:53-54. [PMID: 38105133 DOI: 10.1016/j.carrev.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Andrew S P Sharp
- Dept of Cardiology, University Hospital of Wales and Cardiff University, Cardiff, UK.
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
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Ismayl M, Ismayl A, Hamadi D, Aboeata A, Goldsweig AM. Catheter-directed thrombolysis versus thrombectomy for submassive and massive pulmonary embolism: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 60:43-52. [PMID: 37833203 DOI: 10.1016/j.carrev.2023.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/11/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Controversy surrounds the optimal therapy for submassive and massive pulmonary embolism (PE). We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus surgical and catheter-based thrombectomy in patients with submassive and massive PE. METHODS We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of CDT versus thrombectomy in submassive and massive PE. Studies were identified and data were extracted by two independent reviewers. A random effects model was used to calculate risk ratios (RRs) with 95 % confidence intervals (CIs). Outcomes included in-hospital mortality, procedural complications, hospital and intensive care unit (ICU) length of stay (LOS), 30-day readmissions, and right ventricle/left ventricle (RV/LV) ratio improvement. RESULTS Eight observational studies with 1403 patients were included, of whom 50.0 % received CDT. Compared to thrombectomy, CDT was associated with significantly lower in-hospital mortality (RR 0.62; 95 % CI 0.43-0.89; p = 0.01) and similar rates of major bleeding (p = 0.61), blood transfusion (p = 0.41), stroke (p = 0.41), and atrial fibrillation (p = 0.71). The hospital and ICU LOS, 30-day readmissions, and degree of RV/LV ratio improvement were similar between the two strategies (all p > 0.1). In subgroup analyses, in-hospital mortality was similar between CDT and catheter-based thrombectomy (p = 0.48) but lower with CDT compared with surgical thrombectomy (p = 0.01). CONCLUSIONS In patients with submassive and massive PE, CDT was associated with similar in-hospital mortality compared to catheter-based thrombectomy, but lower in-hospital mortality compared to surgical thrombectomy. Procedural complications, LOS, 30-day readmissions, and RV/LV ratio improvement were similar between CDT and any thrombectomy. Randomized controlled trials are indicated to confirm our findings.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Ahmad Ismayl
- Department of Medicine, Northern General Hospital, Sheffield, UK
| | - Dana Hamadi
- Department of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Aboeata
- Department of Cardiovascular Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center and University of Massachusetts-Baystate, Springfield, MA, USA
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Salinas P, Vázquez-Álvarez ME, Salvatella N, Ruiz Quevedo V, Velázquez Martín M, Valero E, Rumiz E, Jurado-Román A, Lozano Í, Gallardo F, Amat-Santos IJ, Lorenzo Ó, Portero Portaz JJ, Huanca M, Nombela-Franco L, Vaquerizo B, Ramallal Martínez R, Maneiro Melón NM, Sanchis J, Berenguer A, Gallardo-López A, Gutiérrez-Ibañes E, Mejía-Rentería H, Córdoba-Soriano JG, Jiménez-Mazuecos JM. Catheter-directed therapy for acute pulmonary embolism: results of a multicenter national registry. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:138-147. [PMID: 37354942 DOI: 10.1016/j.rec.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/01/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION AND OBJECTIVES Catheter-directed therapy (CDT) for acute pulmonary embolism (PE) is an emerging therapy that combines heterogeneous techniques. The aim of the study was to provide a nationwide contemporary snapshot of clinical practice and CDT-related outcomes. METHODS This Investigator-initiated multicenter registry aimed to include consecutive patients with intermediate-high risk (IHR) or high-risk (HR), acute PE eligible for CDT. The primary outcome of the study was in-hospital all-cause death. RESULTS A total of 253 patients were included, of whom 93 (36.8%) had HR-PE, and 160 (63.2%) had IHR-PE with a mean age of 62.3±15.1 years. Local thrombolysis was performed in 70.8% and aspiration thrombectomy in 51.8%, with 23.3% of patients receiving both. However, aspiration thrombectomy was favored in the HR-PE cohort (80.6% vs 35%; P<.001). Only 51 patients (20.2%) underwent CDT with specific PE devices. The success rate for CDT was 90.9% (98.1% of IHR-PE patients vs 78.5% of HR-PE patients, P<.001). In-hospital mortality was 15.5%, and was highly concentrated in the HR-PE patients (37.6%) and significantly lower in IHR-PE patients (2.5%), P<.001. Long-term (24-month) mortality was 40.2% in HR-PE patients vs 8.2% in IHR-PE patients (P<.001). CONCLUSIONS Despite the high success rate for CDT, in-hospital mortality in HR-PE is still high (37.6%) compared with very low IHR-PE mortality (2.5%).
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Affiliation(s)
- Pablo Salinas
- Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
| | - María-Eugenia Vázquez-Álvarez
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Neus Salvatella
- Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Maite Velázquez Martín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Ernesto Valero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Eva Rumiz
- Servicio de Cardiología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | | | - Íñigo Lozano
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Fernando Gallardo
- Servicio Angiología y Cirugía vascular, Hospital Quirónsalud Marbella, Marbella, Málaga, Spain
| | - Ignacio J Amat-Santos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Óscar Lorenzo
- Servicio de Cardiología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | - Mike Huanca
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Luis Nombela-Franco
- Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Beatriz Vaquerizo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Cardiología Intervencionista, Servicio de Cardiología, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain; Grupo de Investigación Biomédica en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Nicolás Manuel Maneiro Melón
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Juan Sanchis
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Alberto Berenguer
- Servicio de Cardiología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | | | - Enrique Gutiérrez-Ibañes
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Hernán Mejía-Rentería
- Servicio de Cardiología, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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11
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Gonsalves CF, Gibson CM, Stortecky S, Alvarez RA, Beam DM, Horowitz JM, Silver MJ, Toma C, Rundback JH, Rosenberg SP, Markovitz CD, Tu T, Jaber WA. Randomized controlled trial of mechanical thrombectomy vs catheter-directed thrombolysis for acute hemodynamically stable pulmonary embolism: Rationale and design of the PEERLESS study. Am Heart J 2023; 266:128-137. [PMID: 37703948 DOI: 10.1016/j.ahj.2023.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND The identification of hemodynamically stable pulmonary embolism (PE) patients who may benefit from advanced treatment beyond anticoagulation is unclear. However, when intervention is deemed necessary by the PE patient's care team, data to select the most advantageous interventional treatment option are lacking. Limiting factors include major bleeding risks with systemic and locally delivered thrombolytics and the overall lack of randomized controlled trial (RCT) data for interventional treatment strategies. Considering the expansion of the pulmonary embolism response team (PERT) model, corresponding rise in interventional treatment, and number of thrombolytic and nonthrombolytic catheter-directed devices coming to market, robust evidence is needed to identify the safest and most effective interventional option for patients. METHODS The PEERLESS study (ClinicalTrials.gov identifier: NCT05111613) is a currently enrolling multinational RCT comparing large-bore mechanical thrombectomy (MT) with the FlowTriever System (Inari Medical, Irvine, CA) vs catheter-directed thrombolysis (CDT). A total of 550 hemodynamically stable PE patients with right ventricular (RV) dysfunction and additional clinical risk factors will undergo 1:1 randomization. Up to 150 additional patients with absolute thrombolytic contraindications may be enrolled into a nonrandomized MT cohort for separate analysis. The primary end point will be assessed at hospital discharge or 7 days post procedure, whichever is sooner, and is a composite of the following clinical outcomes constructed as a hierarchal win ratio: (1) all-cause mortality, (2) intracranial hemorrhage, (3) major bleeding, (4) clinical deterioration and/or escalation to bailout, and (5) intensive care unit admission and length of stay. The first 4 components of the win ratio will be adjudicated by a Clinical Events Committee, and all components will be assessed individually as secondary end points. Other key secondary end points include all-cause mortality and readmission within 30 days of procedure and device- and drug-related serious adverse events through the 30-day visit. IMPLICATIONS PEERLESS is the first RCT to compare 2 different interventional treatment strategies for hemodynamically stable PE and results will inform strategy selection after the physician or PERT determines advanced therapy is warranted.
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Affiliation(s)
| | | | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | | | - Daren M Beam
- Indiana University Health University Hospital, Indianapolis, IN
| | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John H Rundback
- Advanced Interventional & Vascular Services, LLP, Teaneck, NJ
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12
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Sun B, Chen RR. A comparison of the efficacy and safety between anticoagulation alone and combined with catheter-directed thrombolysis for treatment of pulmonary embolism on outcome: A systematic review and meta-analysis. Perfusion 2023:2676591231211753. [PMID: 37902217 DOI: 10.1177/02676591231211753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND Catheter-directed thrombolysis (CDT) is one of the newest treatment options for submassive pulmonary embolism (sPE). This study will compare the efficacy and safety of catheter-directed thrombolysis (CDT) combine with anticoagulation versus anticoagulation alone (AC) in patients with PE. METHODS A database search was conducted using PubMed, EMBASE, Cochrane Library, and Clinicaltrials.gov for trials that compared CDT with AC in patients with pulmonary embolism. The primary outcomes was1-year mortality. The secondary outcomes were in-hospital, 30 days, 90 days mortality, in-hospital major and minor bleeding (Thrombolysis in Myocardial Infarction (TIMI) classification), length of hospital stay (LOS), reduction of pulmonary arterial systolic pressure (PASP) and RV/LV diameter ratio. RESULTS A total of 16 articles (3 RCTs and 13 non-RCTs) and 10595 patients were included in this study. 2237 patients were in the CDT group and 8358 patients were in the AC group. CDT group was associated with significantly lower in-hospital mortality (2.1% vs 6.2%,OR:0.36, 95%CI:0.26-0.51, p < .00001,I2 = 0%), 30 days mortality (3.1% vs 8.6%,OR:0.39,95%CI:0.23-0.66, p = .0005, I2 = 0%), 90 days mortality (3.8% vs 7.7%,OR:0.49,95%CI:0.29-0.80,p = .005,I2 = 7%), 1-year mortality (6.1% vs 11%, OR:0.51, 95%CI:0.35-0.76, p = .0008,I2 = 36%) compared to AC group, especially in ultrasound-assisted thrombolysis (USAT) subgroup. There were no differences on major bleeding between two groups (1.8% vs 2.2%, OR:1.10, 95%CI:0.61-1.98, p = .75, I2 = 0%). Minor bleeding was significantly higher in CDT group than AC group (6.2% vs 3.8%, OR:1.93,95%CI:1.27-2.94.66, p = .002, I2 = 1%). CDT group significantly reduced PASP (WMD:11.90,95%CI:6.45-17.35, p < .0001, I2 = 72%) and RV/LV (WMD:0.17,95%CI:0.04-0.30, p = .009, I2 = 69%) rapidly than AC group after treatment. LOS was similar between two groups (WMD:0.02,95%CI: -0.68-0.73, p = .95, I2 = 51%). CONCLUSION Results thus confirmed that CDT reduced in-hospital, 30 days, 90 days and 1-year all-cause mortality in patients with sPE compared to AC, particularly in USAT subgroup. Nonetheless, CDT group was associated with a higher risk of minor bleeding.
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Affiliation(s)
| | - Rui Rui Chen
- Department of Cardiology, Tang Du Hospital, Air Force Medical University, Shaanxi, China
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13
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Lauder L, Pérez Navarro P, Götzinger F, Ewen S, Al Ghorani H, Haring B, Lepper PM, Kulenthiran S, Böhm M, Link A, Scheller B, Mahfoud F. Mechanical thrombectomy in intermediate- and high-risk acute pulmonary embolism: hemodynamic outcomes at three months. Respir Res 2023; 24:257. [PMID: 37880651 PMCID: PMC10601326 DOI: 10.1186/s12931-023-02552-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy has been shown to reduce thrombus burden and pulmonary artery pressure (PAP) and to improve right ventricular (RV) function in patients with high-risk or intermediate-high-risk pulmonary embolism (PE). As hemodynamic data after mechanical thrombectomy for PE are scarce, we aimed to assess the hemodynamic effects of mechanical thrombectomy in acute PE with right heart overload. METHODS In this prospective, open-label study, patients with acute symptomatic, computed tomography-documented PE with signs of right heart overload underwent mechanical thrombectomy using the FlowTriever System. Right heart catheterization was performed immediately before and after thrombectomy and after three months. Transthoracic echocardiography was performed before thrombectomy, discharge, and at three months. This analysis was done after 20 patients completed three months of follow-up. RESULTS Twenty-nine patients (34% female) underwent mechanical thrombectomy, of which 20 completed three months follow-up with right heart catheterization. Most patients were at high (17%) or intermediate-high (76%) risk and had bilateral PE (79%). Before thrombectomy, systolic PAP (sPAP) was severely elevated (mean 51.3 ± 11.6 mmHg). Mean sPAP dropped by -15.0 mmHg (95% confidence interval [CI]: -18.9 to -11.0; p < 0.001) immediately after the procedure and continued to decrease from post-thrombectomy to three months (-6.4 mmHg, 95% CI: -10-0 to -2.9; p = 0.002). RV/left ventricular (LV) ratio immediately reduced within two days by -0.37 (95% CI: -0.47 to -0.27; p < 0.001). The proportion of patients with a tricuspid annular plane systolic excursion (TAPSE)/sPAP ratio < 0.31 mm/mmHg decreased from 28% at baseline to 0% before discharge and at three months (p = 0.007). There were no procedure-related major adverse events. CONCLUSIONS Mechanical thrombectomy for acute PE was safe and immediately reduced PAP and improved right heart function. The reduction in PAP was maintained at three months follow-up.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany.
| | - Patricia Pérez Navarro
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Felix Götzinger
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Hussam Al Ghorani
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Bernhard Haring
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Andreas Link
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Bruno Scheller
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätskliniken des Saarlandes und Universität des Saarlandes, Homburg, Germany
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Balakrishna AM, Kalathil RAM, Pusapati S, Atreya A, Mehta A, Bansal M, Aggarwal V, Basir MB, Kochar A, Truesdell AG, Vallabhajosyula S. Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:249-258. [PMID: 37619491 DOI: 10.1016/j.amjcard.2023.07.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.
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Affiliation(s)
| | | | - Suma Pusapati
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Auras Atreya
- Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas School of Medicine, Little Rock, Arkansas
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Mridul Bansal
- Department of Medicine, East Carolina Brody School of Medicine, Greenville, North Carolina
| | - Vikas Aggarwal
- Section of Cardiovascular Medicine, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Mir B Basir
- Section of Cardiovascular Medicine, Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Ajar Kochar
- Section of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | | | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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15
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Duc HN, Hoai LT, Tuan LN, Duc MT, Cong LD. Selective thrombolysis trans-catheter for safe and effective subacute stent graft occlusion treatment. Radiol Case Rep 2023; 18:3549-3552. [PMID: 37547794 PMCID: PMC10403719 DOI: 10.1016/j.radcr.2023.07.031] [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: 05/11/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 08/08/2023] Open
Abstract
A 74-year-old man developed a subacute thrombosis with a stent graft occlusion, 4 months after an endovascular aneurysm repair. He presented with lateral lower limb ischemia and presented intermittent claudication. Using an intra-arterial thrombolysis transcatheter infusion and angioplasty. We report successful endovascular and medical treatment. The patient recovered without complications and was discharged.
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16
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Ho P, Al-Chami F, Caroline M, Gnall E, Bonn J, Greenspon L. Paradoxical pulmonary artery systolic pressure response with catheter-directed therapies for pulmonary embolism. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 34:100320. [PMID: 38510955 PMCID: PMC10946050 DOI: 10.1016/j.ahjo.2023.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 03/22/2024]
Abstract
Background Early data on use of catheter-directed therapies (CDT) for treatment of Intermediate or High-Risk pulmonary embolism (PE) show improvement in pulmonary artery systolic pressures (PAsP) and RV/LV ratios. Occasionally a paradoxical rise in PAsP was observed with CDT utilizing ultrasound-assisted thrombolysis (USAT). It is unclear whether this pattern is seen with CDT utilizing mechanical aspiration. Objectives To investigate and compare the changes in PAsP between those who underwent CDT with USAT to those with mechanical aspiration. Methods A retrospective analysis of those diagnosed with Intermediate or High-Risk PE who underwent CDT using USAT or mechanical aspiration from 7/2013 to 3/2023. The primary outcome was comparison of PAsP changes between the two modalities. Secondary outcomes include length of stay, mortality, and bleeding complications. Results A total of 142 patients were analyzed, of which 93 underwent USAT and 49 underwent mechanical thrombectomy. The mechanical thrombectomy group had significantly lower post-intervention PAsP than the USAT group (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.5 ± 2.7 vs. -7.7 ± 3.2 mmHg. p < 0.0001). A higher frequency of a paradoxical rise in PAsP was observed in the USAT group (22 % vs 4.1 %, p < 0.001). Conclusions CDT utilizing mechanical thrombectomy was associated with lower post-interventional PAsP and greater mean negative change compared to USAT. Occasional paradoxical rises in PAsP were observed with both types of CDT, but they were more frequent with USAT. Hemodynamic monitoring should be considered after CDT. Condensed unstructured abstract We report a retrospective comparison of changes to pulmonary artery systolic pressures (PAsPs) between catheter-directed ultrasound-assisted thrombolysis (USAT) and catheter-directed mechanical thrombectomy in Intermediate and High-Risk pulmonary embolism. Those treated with mechanical thrombectomy compared to USAT had significantly lower post-interventional PAsP (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.2 ± 2.7 vs. -7.5 ± 3.2 mmHg, p < 0.0001). A paradoxical rise in PAsP was observed more frequently in the USAT group than the mechanical thrombectomy group (22 % vs 4.1 %, p < 0.001).
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Affiliation(s)
- Patrick Ho
- Division of Pulmonary & Critical Care Medicine, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Farouk Al-Chami
- Division of Internal Medicine, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Mara Caroline
- Division of Interventional Cardiology, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Eric Gnall
- Division of Interventional Cardiology, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Joseph Bonn
- Division of Interventional Radiology, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Lee Greenspon
- Division of Pulmonary & Critical Care Medicine, Lankenau Medical Center, Wynnewood, PA, United States of America
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17
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Khandait H, Harkut P, Khandait V, Bang V. Acute pulmonary embolism: Diagnosis and management. Indian Heart J 2023; 75:335-342. [PMID: 37207830 PMCID: PMC10568061 DOI: 10.1016/j.ihj.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 05/21/2023] Open
Abstract
Acute pulmonary embolism (PE) can present with non-specific signs and symptoms and thus the diagnosis and management might not be as straightforward. This review outlines the new PE management guidelines in the Indian context. The exact prevalence in the Indian population is not well defined; despite recent studies suggesting an increasing trend in the Asian population. A delay in treatment can be fatal, especially in massive PE. The nuances associated with stratification and management have led to heterogeneity in acute PE management. The purpose of the review is. 1: To highlight the principles of stratification, diagnosis and management of acute PE with a special attention towards the Indian population. 2: To aid patient selection for newer catheter based therapies. To conclude, formulation of pulmonary embolism guidelines in the Indian setting is required underlying the role of further research in this area.
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Affiliation(s)
| | | | | | - Vijay Bang
- Grant Medical College and Sir JJ Group of Hospitals, Maharashtra, India
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18
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Sá Couto D, Alexandre A, Costa R, Campinas A, Santos M, Ribeiro D, Torres S, Luz A. ST-Segment Elevation: An Unexpected Culprit. J Cardiovasc Dev Dis 2023; 10:374. [PMID: 37754803 PMCID: PMC10532326 DOI: 10.3390/jcdd10090374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/28/2023] Open
Abstract
The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1-V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.
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Affiliation(s)
- David Sá Couto
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - André Alexandre
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Ricardo Costa
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
| | - Andreia Campinas
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Mariana Santos
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Diana Ribeiro
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
| | - Severo Torres
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - André Luz
- Cardiology Department, Centro Hospitalar Universitário de Santo António, Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal; (A.A.); (R.C.); (A.C.); (M.S.)
- ICBAS School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
- Cardiovascular Research Group at Unidade Muldisciplinar de Investigação Biomédica (UMIB), ICBAS School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
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19
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Toma C, Jaber WA, Weinberg MD, Bunte MC, Khandhar S, Stegman B, Gondi S, Chambers J, Amin R, Leung DA, Kado H, Brown MA, Sarosi MG, Bhat AP, Castle J, Savin M, Siskin G, Rosenberg M, Fanola C, Horowitz JM, Pollak JS. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism. EUROINTERVENTION 2023; 18:1201-1212. [PMID: 36349702 PMCID: PMC9936254 DOI: 10.4244/eij-d-22-00732] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/09/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Evidence supporting interventional pulmonary embolism (PE) treatment is needed. AIMS We aimed to evaluate the acute safety and effectiveness of mechanical thrombectomy for intermediate- and high-risk PE in a large real-world population. METHODS FLASH is a multicentre, prospective registry enrolling up to 1,000 US and European PE patients treated with mechanical thrombectomy using the FlowTriever System. The primary safety endpoint is a major adverse event composite including device-related death and major bleeding at 48 hours, and intraprocedural adverse events. Acute mortality and 48-hour outcomes are reported. Multivariate regression analysed characteristics associated with pulmonary artery pressure and dyspnoea improvement. RESULTS Among 800 patients in the full US cohort, 76.7% had intermediate-high risk PE, 7.9% had high-risk PE, and 32.1% had thrombolytic contraindications. Major adverse events occurred in 1.8% of patients. All-cause mortality was 0.3% at 48-hour follow-up and 0.8% at 30-day follow-up, with no device-related deaths. Immediate haemodynamic improvements included a 7.6 mmHg mean drop in mean pulmonary artery pressure (-23.0%; p<0.0001) and a 0.3 L/min/m2 mean increase in cardiac index (18.9%; p<0.0001) in patients with depressed baseline values. Most patients (62.6%) had no overnight intensive care unit stay post-procedure. At 48 hours, the echocardiographic right ventricle/left ventricle ratio decreased from 1.23±0.36 to 0.98±0.31 (p<0.0001 for paired values) and patients with severe dyspnoea decreased from 66.5% to 15.6% (p<0.0001). Conclusions: Mechanical thrombectomy with the FlowTriever System demonstrates a favourable safety profile, improvements in haemodynamics and functional outcomes, and low 30-day mortality for intermediate- and high-risk PE.
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Affiliation(s)
- Catalin Toma
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA
| | | | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, NY, USA
| | - Matthew C Bunte
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn Presbyterian Medical Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Stegman
- CentraCare Heart and Vascular Center, St. Cloud, MN, USA
| | | | - Jeffrey Chambers
- Interventional Cardiology, Metropolitan Heart and Vascular Institute, Minneapolis, MN, USA
| | - Rohit Amin
- Ascension Sacred Heart Hospital Pensacola, Pensacola, FL, USA
| | | | - Herman Kado
- Ascension Providence Hospital, Southfield, MI, USA
| | | | | | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, MO, USA
| | - Jordan Castle
- Inland Imaging, Providence Sacred Heart, Spokane, WA, USA
| | - Michael Savin
- Department of Radiology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Gary Siskin
- Department of Radiology, Albany Medical Center, Albany, NY, USA
| | - Michael Rosenberg
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Christina Fanola
- Department of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - James M Horowitz
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jeffrey S Pollak
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
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20
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Inman BL, Long B. What Is the Efficacy of Catheter-Directed Thrombolysis Versus Systemic Anticoagulation Alone for Submassive Pulmonary Embolism? Ann Emerg Med 2022; 81:580-583. [PMID: 36328847 DOI: 10.1016/j.annemergmed.2022.08.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Brannon L Inman
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
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21
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Machanahalli Balakrishna A, Reddi V, Belford PM, Alvarez M, Jaber WA, Zhao DX, Vallabhajosyula S. Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management. Medicina (B Aires) 2022; 58:medicina58091186. [PMID: 36143863 PMCID: PMC9504600 DOI: 10.3390/medicina58091186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.
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Affiliation(s)
| | - Vuha Reddi
- Department of Medicine, Danbury Hospital/Yale University School of Medicine, Danbury, CT 06810, USA
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Manrique Alvarez
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Wissam A. Jaber
- Section of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
| | - David X. Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Correspondence: ; Tel.: +1-(336)-878-6000
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