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Ubaldi N, Krokidis M, Rossi M, Orgera G. Endovascular treatments of acute pulmonary embolism in the post-fibrinolytic era: an up-to-date review. Insights Imaging 2024; 15:122. [PMID: 38767729 PMCID: PMC11106225 DOI: 10.1186/s13244-024-01694-9] [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: 10/27/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024] Open
Abstract
Pulmonary embolism (PE) is a significant contributor to global cardiovascular-related mortality that mainly depends on the severity of the event. The treatment approach for intermediate and high-risk PE remains a topic of debate due to the fine balance between hemodynamic deterioration and bleeding risk. The initial treatment choice for intermediate-risk PE with hemodynamic deterioration and high-risk PE is historically systemic thrombolysis, but this approach is not always effective and carries a notable risk of severe bleeding. For such patients, various interventional treatments have been introduced to clinical practice, including catheter-directed lysis (CDL), ultrasound-assisted CDL, pharmacomechanical CDL, and aspiration thrombectomy. However, the optimal treatment approach remains uncertain. Encouraging outcomes have been presented assessing the novel endovascular treatments, in terms of reducing right ventricular dysfunction and improving hemodynamic stability, opening the possibility of using these devices to prevent hemodynamic instability in less severe cases. However, ongoing randomized trials that assess the efficacy and the association with mortality, especially for aspiration devices, have not yet published their final results. This article aims to offer a comprehensive update of the available catheter-directed therapies for PE, with a focus on novel mechanical thrombectomy techniques, assessing their safety and efficacy, after comparison to the conventional treatment. CRITICAL RELEVANCE STATEMENT: This is a comprehensive review of the indications of use, techniques, and clinical outcomes of the most novel endovascular devices for the treatment of pulmonary embolism. KEY POINTS: Mechanical thrombectomy is an effective tool for patients with PE. Aspiration devices prevent hemodynamic deterioration. Catheter directed therapy reduces bleeding complications.
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Affiliation(s)
- Nicolò Ubaldi
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
| | - Miltiadis Krokidis
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Areteion Hospital, Athens, Greece.
| | - Michele Rossi
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
| | - Gianluigi Orgera
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
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Finocchiaro S, Mauro MS, Rochira C, Spagnolo M, Laudani C, Landolina D, Mazzone PM, Agnello F, Ammirabile N, Faro DC, Imbesi A, Occhipinti G, Greco A, Capodanno D. Percutaneous interventions for pulmonary embolism. EUROINTERVENTION 2024; 20:e408-e424. [PMID: 38562073 PMCID: PMC10979388 DOI: 10.4244/eij-d-23-00895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/19/2024] [Indexed: 04/04/2024]
Abstract
Pulmonary embolism (PE) ranks as a leading cause of in-hospital mortality and the third most common cause of cardiovascular death. The spectrum of PE manifestations varies widely, making it difficult to determine the best treatment approach for specific patients. Conventional treatment options include anticoagulation, thrombolysis, or surgery, but emerging percutaneous interventional procedures are being investigated for their potential benefits in heterogeneous PE populations. These novel interventional techniques encompass catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches combining different mechanisms. Furthermore, inferior vena cava filters are also available as an option for PE prevention. Such interventions may offer faster improvements in right ventricular function, as well as in pulmonary and systemic haemodynamics, in individual patients. Moreover, percutaneous treatment may be a valid alternative to traditional therapies in high bleeding risk patients and could potentially reduce the burden of mortality related to major bleeds, such as that of haemorrhagic strokes. Nevertheless, the safety and efficacy of these techniques compared to conservative therapies have not been conclusively established. This review offers a comprehensive evaluation of the current evidence for percutaneous interventions in PE and provides guidance for selecting appropriate patients and treatments. It serves as a valuable resource for future researchers and clinicians seeking to advance this field. Additionally, we explore future perspectives, proposing "percutaneous primary pulmonary intervention" as a potential paradigm shift in the field.
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Affiliation(s)
- Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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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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Shah S, Ogbonna AV, Nance J, Gregoski MJ, Tedford R, Ramu B, Todoran TM, Litwin SE. A Multimodality Imaging Approach to Defining Risk in Patients With Acute Pulmonary Embolism. J Am Soc Echocardiogr 2023; 36:933-940. [PMID: 37178724 DOI: 10.1016/j.echo.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/22/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Morbidity and mortality for acute pulmonary embolism (PE) remain high. Therapies such as catheter-directed thrombolysis may improve outcomes, but these are generally reserved for higher-risk patients. Imaging may help guide the use of the newer therapies, but current guidelines focus more on clinical factors. Our goal was to create a risk model that incorporated quantitative echocardiographic and computed tomography (CT) measures of right ventricular (RV) size and function, thrombus burden, and serum biomarkers of cardiac overload or injury. METHODS This was a retrospective study of 150 patients evaluated by a PE response team. Echocardiography was performed within 48 hours of diagnosis. Computed tomography measures included RV/left ventricular (LV) ratio and thrombus load (Qanadli score). Echocardiography was used to obtain various quantitative measures of RV function. We compared characteristics of those who met the primary endpoint (7-day mortality and clinical deterioration) to those who did not. Receiver operating curve analysis was used to assess the performance of different combinations of clinically relevant features and the association with adverse outcomes. RESULTS Fifty-two percent of patients were female, with age 62 ± 17 years, systolic blood pressure 123 ± 25 mm Hg, heart rate 98 ± 19, troponin 3.2 ± 35 ng/dL, and b-type natriuretic peptide (BNP) 467 ± 653. Fourteen (9.3%) were treated with systemic thrombolytics, 27 (18%) underwent catheter-directed thrombolytics, 23 (15%) were intubated or required vasopressors, and 14 (9.3%) died. Patients who met the primary endpoint (44%) versus those who did not (56%) had lower RV S' (6.6 vs 11.9 cm/sec; P < .001) and RV free wall strain (-10.9% vs -13.6%; P = .005), higher RV/LV ratio on CT, and higher serum BNP and troponin levels. Receiver operating curve analysis demonstrated an area under the curve of 0.89 for a model that included RV S', RV free wall strain and tricuspid annular plane systolic excursion/RV systolic pressure ratio from echo, thrombus load and RV/LV ratio from CT, and troponin and BNP levels. CONCLUSION A combination of clinical, echo, and CT findings that reflect the hemodynamic effects of the embolism identified patients with adverse events related to acute PE. Optimized scoring systems that focus on reversible abnormalities attributable to PE may allow more appropriate triaging of intermediate- to high-risk patients with PE for early interventional strategy.
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Affiliation(s)
- Shailee Shah
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Alexis Violette Ogbonna
- Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jay Nance
- Houston Methodist Academic Institute, Houston, Texas
| | - Mathew J Gregoski
- Department of Public Health Services, Medical University of South Carolina, Charleston, South Carolina
| | - Ryan Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Bhavadharini Ramu
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina; Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Thomas M Todoran
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina; Department of Medicine, Division of Cardiology, Ralph H. Johnson Veterans Affairs Health Network, Charleston, South Carolina
| | - Sheldon E Litwin
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina; Department of Medicine, Division of Cardiology, Ralph H. Johnson Veterans Affairs Health Network, Charleston, South Carolina.
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5
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Ishisaka Y, Watanabe A, Fujisaki T, Iwagami M, So M, Steiger D, Aoi S, Secemsky EA, Wiley J, Kuno T. Comparison of interventions for intermediate to high-risk pulmonary embolism: A network meta-analysis. Catheter Cardiovasc Interv 2023; 102:249-265. [PMID: 37269229 DOI: 10.1002/ccd.30745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Multiple interventions, including catheter-directed therapy (CDT), systemic thrombolysis (ST), surgical embolectomy (SE), and therapeutic anticoagulation (AC) have been used to treat intermediate to high-risk pulmonary embolism (PE), but the most effective and safest treatment remains unclear. Our study aimed to investigate the efficacy and safety outcomes of each intervention. METHODS We queried PubMed and EMBASE in January 2023 and performed a network meta-analysis of observational studies and randomized controlled trials (RCT), including high or intermediate-risk PE patients, and comparing AC, CDT, SE, and ST. The primary outcomes were in-hospital mortality and major bleeding. The secondary outcomes included long-term mortality (≥6 months), recurrent PE, minor bleeding, and intracranial hemorrhage. RESULTS We identified 11 RCTs and 42 observational studies involving 157,454 patients. CDT was associated with lower in-hospital mortality than ST (odds ratio [OR] [95% confidence interval (CI)]: 0.41 [0.31-0.55]), AC (OR [95% CI]: 0.33 [0.20-0.53]), and SE (OR [95% CI]: 0.61 [0.39-0.96]). Recurrent PE in CDT was lower than ST (OR [95% CI]: 0.66 [0.50-0.87]), AC (OR [95% CI]: 0.36 [0.20-0.66]), and trended lower than SE (OR [95% CI]: 0.71 [0.40-1.26]). Notably, ST had higher major bleeding risks than CDT (OR [95% CI]: 1.51 [1.19-1.91]) and AC (OR [95% CI]: 2.21 [1.53-3.19]). By rankogram analysis, CDT presented the highest p-score in in-hospital mortality, long-term mortality, and recurrent PE. CONCLUSION In this network meta-analysis of observational studies and RCTs involving patients with intermediate to high-risk PE, CDT was associated with improved mortality outcomes compared to other therapies, without significant additional bleeding risk.
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Affiliation(s)
- Yoshiko Ishisaka
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Atsuyuki Watanabe
- Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, University of Kumamoto, Kumamoto, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Matsuo So
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - David Steiger
- Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Shunsuke Aoi
- Division of Cardiology, Billings Clinic, Billing, Montana, USA
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
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Goldschmied A, Geisler T. [Thromboembolic diseases from a cardiological point of view]. Dtsch Med Wochenschr 2023; 148:908-914. [PMID: 37493952 DOI: 10.1055/a-1825-7296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Thromboembolic disease is associated with a high mortality. It can be divided into two groups: embolism from a venous and embolism from an arterial side. This article gives an overview on thromboembolic disease (with a focus on pulmonary embolism and ischemic stroke) from a cardiologist's perspective.The therapeutic options for acute pulmonary embolism range from anticoagulation to fibrinolysis to interventional recanalization and surgery. The deciding factor for choice of therapy is the risk of early death. Besides clinical parameters, laboratory markers like cardiac troponin and right ventricular function on echocardiography or CTPA (computed tomography pulmonary angiography) are used to determine the early mortality risk. In hemodynamically instable patients, immediate thrombolysis is required, whereas patients with intermediate and low risk can be treated with anticoagulation. Interventional recanalization is currently being studied in patients at risk for development of CTEPH (chronic thromboembolic pulmonary hypertension) or an intermediate risk of early mortality.In ischemic stroke, early interdisciplinary workup involving a cardiologist is paramount. Post stroke screening should include monitoring for arrythmias (especially atrial fibrillation) and transthoracic echocardiography as well as sonography of extra- and intracranial arteries. If no embolic source can be detected (embolic stroke of undetermined source), transesophageal echo can be helpful to detect intracardiac shunts like patent foramen ovale (PFO) or intracardiac tumors. Post stroke care includes secondary prevention measures like risk factor modification and lipid lowering therapy as well as anticoagulation. In high risk for paradoxical embolization, interventional PFO closure can be performed. Interventional closure of the left atrial appendage (LAA) can be discussed in patients with both high thromboembolic and bleeding risk.
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Calé R, Pereira H, Ferreira F, Loureiro MJ. Blueprint for developing an effective pulmonary embolism response network. Rev Port Cardiol 2023:S0870-2551(23)00123-3. [PMID: 36893841 DOI: 10.1016/j.repc.2022.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/24/2021] [Accepted: 06/17/2022] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a major cause of morbidity and mortality in Portugal. It is the third most common cause of cardiovascular death after stroke and myocardial infarction. However, the management of acute PE remains poorly standardized, and there is a lack of access to mechanical reperfusion when indicated. METHODS AND RESULTS This working group analyzed the current clinical guidelines for the use of percutaneous catheter-directed treatment in this setting and proposed a standardized approach for severe forms of acute PE. This document also proposes a methodology for the coordination of regional resources in order to create an effective PE response network, based on the hub-and-spoke organization design. CONCLUSION This model can be applied at the regional level, but it is desirable to extend it to the national level.
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Affiliation(s)
- Rita Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - Hélder Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal; CCUL, CAML, University of Lisbon, Lisbon, Portugal
| | - Filipa Ferreira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
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KHREBTIY Y, CHERNUKHA L. Aspiration rotational thrombectomy in treatment of pulmonary embolism. ACTA PHLEBOLOGICA 2023. [DOI: 10.23736/s1593-232x.22.00552-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Ramos-López N, Ferrera C, Luque T, Enríquez-Vázquez D, Mahía-Casado P, Galván-Herráez L, Pedrajas JM, Salinas P, Fraile PZ, Islas F, Real C, Mejía-Rentería H, Jiménez-Quevedo P, Gonzalo N, Nuñez-Gil I, Nombela-Franco L, Tirado G, Macaya F, Escaned J, Hernández AMM, Bustamante J, Serrano MP, García EB, Pozzi MAO, Higueras J, Agustín AD, Viana-Tejedor A, Fernández-Ortiz A. Impact of a pulmonary embolism response team initiative on hospital mortality of patients with bilateral pulmonary embolism. Med Clin (Barc) 2023:S0025-7753(23)00017-9. [PMID: 36801109 DOI: 10.1016/j.medcli.2022.12.017] [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: 07/01/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) response teams (PERT) for the management of high-risk PE (HR-PE) and intermediate-high risk PE (IHR-PE) are encouraged in PE guidelines. We aimed to assess the impact of a PERT initiative on mortality in these groups of patients, compared with standard care. METHODS We conducted a prospective, single-center registry, including consecutive patients with HR-PE and IHR-PE with PERT activation from February-2018 to December-2020 (PERT group, n=78 patients) and compared it with an historic cohort of patients admitted to our hospital in a previous 2-year period (2014-2016), managed with standard of care (SC-group, n=108 patients). RESULTS Patients in the PERT group were younger and less comorbid. The risk profile at admission and the percentage of HR-PE was similar in both cohorts (13% in SC-group and 14% in PERT-group, p=0.82). Reperfusion therapy was more frequently indicated in PERT-group (24.4% vs 10.2%, p=0.01), with no differences in fibrinolysis treatment, while catheter-directed therapy (CDT) was more frequent in PERT group (16.7% vs 1.9%, p<0.001). Reperfusion and CDT were associated with lower in-hospital mortality (2.9% vs 15.1%, p=0.001 for reperfusion and 1.5% vs 16.5%, p=0.001 for CDT). The primary outcome, 12-month mortality, was lower in the PERT-group (9% vs 22.2%, p=0.02), There were no differences in 30-day readmissions. In multivariate analysis PERT activation was associated with lower mortality at 12 months (HR 0.25, 95% confidence interval 0.09-0.7, p=0.008). CONCLUSION A PERT initiative in patients with HR-PE and IHR-PE was associated with a significant reduction in 12-month mortality compared with standard of care, and also with an increase in the use of reperfusion, especially catheter-directed therapies.
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Affiliation(s)
- Noemi Ramos-López
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Carlos Ferrera
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Tania Luque
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | | | | | - José María Pedrajas
- Internal Medicine Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Pablo Salinas
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain.
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Klok FA, Piazza G, Sharp ASP, Ní Ainle F, Jaff MR, Chauhan N, Patel B, Barco S, Goldhaber SZ, Kucher N, Lang IM, Schmidtmann I, Sterling KM, Becker D, Martin N, Rosenfield K, Konstantinides SV. Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: Rationale and design of the HI-PEITHO study. Am Heart J 2022; 251:43-53. [PMID: 35588898 DOI: 10.1016/j.ahj.2022.05.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 05/21/2023]
Abstract
BACKGROUND Due to the bleeding risk of full-dose systemic thrombolysis and the lack of major trials focusing on the clinical benefits of catheter-directed treatment, heparin antiocoagulation remains the standard of care for patients with intermediate-high-risk pulmonary embolism (PE). METHODS AND RESULTS The Higher-Risk Pulmonary Embolism Thrombolysis (HI-PEITHO) study (ClinicalTrials.gov Identifier: NCT04790370) is a multinational multicenter randomized controlled parallel-group comparison trial. Patients with: (1) confirmed acute PE; (2) evidence of right ventricular (RV) dysfunction on imaging; (3) a positive cardiac troponin test; and (4) clinical criteria indicating an elevated risk of early death or imminent hemodynamic collapse, will be randomized 1:1 to treatment with a standardized protocol of ultrasound-facilitated catheter-directed thrombolysis plus anticoagulation, vs anticoagulation alone. The primary outcome is a composite of PE-related mortality, cardiorespiratory decompensation or collapse, or non-fatal symptomatic and objectively confirmed PE recurrence, within 7 days of randomization. Further assessments cover, apart from bleeding complications, a broad spectrum of functional and patient-reported outcomes including quality of life indicators, functional status and the utilization of health care resources over a 12-month follow-up period. The trial plans to include 406 patients, but the adaptive design permits a sample size increase depending on the results of the predefined interim analysis. As of May 11, 2022, 27 subjects have been enrolled. The trial is funded by Boston Scientific Corporation and through collaborative research agreements with University of Mainz and The PERT Consortium. CONCLUSIONS Regardless of the outcome, HI-PEITHO will establish the first-line treatment in intermediate-high risk PE patients with imminent hemodynamic collapse. The trial is expected to inform international guidelines and set the standard for evaluation of catheter-directed reperfusion options in the future.
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Affiliation(s)
- Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Fionnuala Ní Ainle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | | | | | - Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland; Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Nils Kucher
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Irene M Lang
- Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Keith M Sterling
- Department of Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, VA
| | - Dorothea Becker
- Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Nadine Martin
- Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Kenneth Rosenfield
- Division of Vascular Medicine and Intervention, Massachusetts General Hospital, Boston, MA
| | - Stavros V Konstantinides
- Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
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Cueto-Robledo G, Rivera-Sotelo N, Roldan-Valadez E, Narvaez-Oriani CA, Cueto-Romero HD, Gonzalez-Hermosillo LM, Hidalgo-Alvarez M, Barrera-Jimenez B. A brief review on failed hybrid treatment for massive pulmonary embolism: catheter-directed thrombolysis (CDT) and pharmaco-mechanical thrombolysis (PMT). Curr Probl Cardiol 2022; 47:101294. [PMID: 35753399 PMCID: PMC9225962 DOI: 10.1016/j.cpcardiol.2022.101294] [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: 06/12/2022] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
Acute massive or high-risk pulmonary embolism (PE), described as a lung arteries occlusion by an embolus, causes a significant compromise of hemodynamic stability and could lead to a lethal event. Systemic fibrinolytic therapy has been accepted as the standard reperfusion therapy in massive PE, except when there is an increased risk of bleeding. Catheter-based mechanical strategies (thrombofragmentation, thromboaspiration with catheter-guided thrombolysis) are described as options when there are absolute contraindications to systemic thrombolysis. We briefly reviewed clinical situations when patients with severe pneumonia due to COVID-19 are complicated by a high-risk saddle pulmonary embolism and underwent repeated pharmacomechanical thrombolysis and high-flow oxygen therapy. There are scarce reports of failed catheter-guided pharmacomechanical thrombolysis in patients with PE secondary to COVID-19. Re-administration of systemic thrombolysis and alteplase (15 mg dose) can show favorable results.
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Affiliation(s)
- Guillermo Cueto-Robledo
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico.
| | - Nathaly Rivera-Sotelo
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr Eduardo Liceaga", Mexico City, Mexico; I.M. Sechenov First Moscow State Medical Universit (Sechenov University), Department of Radiology, Moscow, Russia.
| | | | | | - Leslie-Marisol Gonzalez-Hermosillo
- Directorate of Research, Hospital General de Mexico "Dr Eduardo Liceaga", Mexico City, Mexico; I.M. Sechenov First Moscow State Medical Universit (Sechenov University), Department of Radiology, Moscow, Russia
| | - Martin Hidalgo-Alvarez
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Beatriz Barrera-Jimenez
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
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12
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Pietrasik A, Gąsecka A, Szarpak Ł, Pruc M, Kopiec T, Darocha S, Banaszkiewicz M, Niewada M, Grabowski M, Kurzyna M. Catheter-Based Therapies Decrease Mortality in Patients With Intermediate and High-Risk Pulmonary Embolism: Evidence From Meta-Analysis of 65,589 Patients. Front Cardiovasc Med 2022; 9:861307. [PMID: 35783825 PMCID: PMC9243366 DOI: 10.3389/fcvm.2022.861307] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Catheter-directed therapies (CDT) are an alternative to systemic thrombolysis (ST) in pulmonary embolism (PE) patients, but the mortality benefit of CDT is unclear. Objective We conducted a systematic review with meta-analysis to compare the efficacy and safety of CDT and ST in intermediate-high and high-risk PE. Methods We included (P) participants, adult PE patients; (I) intervention, CDT; (C) comparison, ST; (O) outcomes, mortality, complications, in-hospital treatment, and length of hospital stay; (S) study design, randomized controlled trials (RCTs), or cohort comparing CDT and ST. The primary endpoint was 30-day mortality. Secondary outcomes included treatment-related complications including bleeding, the use of hospital resources, and length of hospital stay. Results Eleven studies including 65,589 patients met the inclusion criteria. Thirty-day mortality was lower in the CDT group, compared to ST group [7.3 vs. 13.6%; odds ratio (OR) = 0.51, 95% confidence interval (CI) 0.38–0.69, p < 0.001]. The rates of myocardial injury, cardiac arrest, and stroke were lower in CDT group, compared to ST group (p < 0.001 for all). The rates of any major bleeding, intracranial hemorrhage, hemoptysis, and red blood cell transfusion were lower in patients treated with CDT, compared to ST (p ≤ 0.01 for all). Extracorporeal life support was used more often in patients treated with CDT, compared to ST (0.5 vs. 0.2%, OR = 2.52, 95% CI 1.88–3.39, p < 0.001). The use of hospital resources and length of hospital stay were comparable in both groups. Conclusion CDT might decrease mortality in patients with intermediate-high and high-risk PE and were associated with fewer complications, including major bleeding.
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Affiliation(s)
- Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Arkadiusz Pietrasik,
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Szarpak
- Research Unit, Maria Sklodowska-Curie Białystok Oncology Center, Białystok, Poland
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland
| | - Michał Pruc
- Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland
| | - Tomasz Kopiec
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, Otwock, Poland
| | - Marta Banaszkiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, Otwock, Poland
| | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, Otwock, Poland
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13
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Akbal ÖY, Keskin B, Tokgöz HC, Hakgör A, Karagöz A, Tanyeri S, Kültürsay B, Külahçıoğlu Ş, Bayram Z, Efe S, Erkılınç A, Tanboğa İH, Doğan C, Akbulut M, Özdemir N, Kaymaz C. A seven-year single-center experience on AngioJet rheolytic thrombectomy in patients with pulmonary embolism at high risk and intermediate-high risk. Anatol J Cardiol 2021; 25:902-911. [PMID: 34866585 DOI: 10.5152/anatoljcardiol.2021.28303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIM Angiojet Rheolytic thrombectomy (ART) has been utilized as a catheter-based treatment in acute pulmonary embolism (PE). In this study based on our seven-year experience on ART in patients with PE, we evaluated efficacy and safety outcomes of ART. METHODS Our study is based on retrospective evaluation of 56 patients with high- and intermediate-high-risk PE, age (62 years; interquartile-range (IQR): 50-73) who underwent ART. RESULTS High- and intermediate-high-risk were noted in 21.4 % and in 78.6 % of patients, respectively. ART duration was 304(IQR: 246-468) seconds. Measures of obstruction, right to left ventricle diameter ratio (RV/LV ratio), right to left atrial diameter ratio and pulmonary arterial pressures were improved (p<0.001 for all). During hospital stay, acute renal failure, major and minor bleeding, and mortality rates were 37.5%, 7.1%, 12.5%, and 8.9%, respectively. Aging related to post-procedural nephropathy while high-risk status was associated with in-hospital mortality (p=0.006) and long-term mortality. CONCLUSIONS The ART resulted in significant and clinically relevant improvements in the pulmonary arterial thrombotic burden, RV strain and hemodynamics in patients with PE at high- and intermediate-high-risk. Aging increased the risk of post-procedural nephropathy whereas baseline high-risk status predicted in-hospital and long-term mortality.
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Affiliation(s)
- Özgur Yaşar Akbal
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Berhan Keskin
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Hacer Ceren Tokgöz
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Aykun Hakgör
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Ali Karagöz
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Seda Tanyeri
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Barkın Kültürsay
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Şeyhmus Külahçıoğlu
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Zübeyde Bayram
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Süleyman Efe
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Atakan Erkılınç
- Department of Anesthesiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - İbrahim Halil Tanboğa
- Department of Cardiology, Faculty of Medicine, Nişantaşı University; İstanbul-Turkey
| | - Cem Doğan
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Mehmet Akbulut
- Department of Cardiology, Faculty of Medicine, Fırat University; Elazığ-Turkey
| | - Nihal Özdemir
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, Hamidiye Faculty of Medicine, University of Health Sciences Turkey, Koşuyolu Heart Training and Research Hospital; İstanbul-Turkey
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14
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Hassan AKM, Ahmed H, Ahmed Y, Elfadl AEA, Omar A. Efficacy and safety of hydro-mechanical defragmentation in intermediate- and high-risk pulmonary embolism. Egypt Heart J 2021; 73:84. [PMID: 34564780 PMCID: PMC8464550 DOI: 10.1186/s43044-021-00204-2] [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: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is the third most common acute cardiovascular syndrome. Percutaneous catheter directed hydro-mechanical defragmentation (HMD) is one of the recommended treatment options for PE in patients with contraindications to thrombolytic therapy or failed systemic thrombolysis (ST). We aimed to identify the safety and outcomes of catheter directed HMD in patients with high-risk PE. This nonrandomized controlled trial enrolled all patients with confirmed diagnoses of high- and intermediate-high-risk PE from October 2019 till January 2021. Fifty patients were included and divided into two groups by the PE response team according to the presence or absence of a contraindication for ST. Group B (ST) consists of 25 patients and group A (HMD) of 25 patients who cannot receive ST. RESULTS The two groups were comparable regarding baseline clinical characteristics with mean age 51 ± 13 years. In group A, systolic blood pressure (BP) and oxygen saturation increased after 24 h (p = 0.002) and 48 h (p < 0.001) compared to pre-HMD procedure. Mean pulmonary artery systolic pressure (PASP) and respiratory rate (RR) decreased after 48 h and at 30 days (p < 0.001) compared to pre-HMD procedure. The increase in systolic BP and oxygen saturation were significantly higher in HMD group compared with ST group after 48 h and at 30 days (p < 0.007). The decrease in PASP and RR was significantly higher in HMD group compared to ST group after 48 h and at 30 days (p < 0.001). Mortality rate at 30 days was 20% in HMD group compared to 32% in ST group. CONCLUSIONS Catheter directed HMD for high-risk and intermediate-high-risk PE is safe and effective with acceptable mortality Trial registration Clinical trial ID: NCT04099186.
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Affiliation(s)
| | - Heba Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | - Yousef Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | | | - Amany Omar
- Chest Department, Assiut University, Asyut, Egypt
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15
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Wasserstrum Y, Lubetzky A, Goitein O, Matetzky S. A patient with pulmonary embolism takes a surprising HIT: a case report. Eur Heart J Case Rep 2021; 5:ytab304. [PMID: 34476337 PMCID: PMC8407492 DOI: 10.1093/ehjcr/ytab304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/07/2021] [Accepted: 07/13/2021] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Venous thromboembolism (VTE) is a common condition that may manifest as intermediate or high-risk pulmonary embolism (PE), requiring either primary or subsequent fibrinolytic therapy. In these cases, catheter-directed thrombolysis (CDT) has been shown to be beneficial.
Case summary
We present the case of a borderline obese but otherwise healthy 43-year-old male individual, who was admitted with acute intermediate- to high-risk PE requiring treatment with intravenous unfractionated heparin. After initial therapy failure, the patient received CDT, with subsequent clinical worsening, and a mixed result of imaging studies suggesting partial central worsening and partial peripheral improvement of the thrombotic burden and right ventricular (RV) function. After a multidisciplinary PE response team (PERT) consultation, the diagnosis of heparin-induced thrombocytopenia (HIT) with normal platelet levels was made. Therapy was changed to intravenous bivalirudin, with an excellent clinical response and complete recovery of RV function. The patient was discharged with oral rivaroxaban therapy, and on follow-up was otherwise well.
Discussion
Apparent failure of thrombolytic therapy for VTE warrants a clinical investigation into possible causes of a pro-thrombotic state. In this case, the diagnosis of HIT was surprising, especially due to only a mild decline in platelet levels that were well within normal range. We also acknowledge the significance of our PERT in the key diagnosis made in this case.
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Affiliation(s)
- Yishay Wasserstrum
- Leviev Center of Cardiovascular Medicine, Sheba Medical Center in Tel-Ha’Shomer, Ramat-Gan, Israel, 5232000
- Sackler School of Medicine, Tel-Aviv University, 35th Klatshkin st., Tel-Aviv, Israel, 6997801
| | - Aaron Lubetzky
- Sackler School of Medicine, Tel-Aviv University, 35th Klatshkin st., Tel-Aviv, Israel, 6997801
- National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center in Tel-Ha’Shomer, Ramat-Gan, Israel, 5232000
| | - Orly Goitein
- Leviev Center of Cardiovascular Medicine, Sheba Medical Center in Tel-Ha’Shomer, Ramat-Gan, Israel, 5232000
- Sackler School of Medicine, Tel-Aviv University, 35th Klatshkin st., Tel-Aviv, Israel, 6997801
| | - Shlomo Matetzky
- Leviev Center of Cardiovascular Medicine, Sheba Medical Center in Tel-Ha’Shomer, Ramat-Gan, Israel, 5232000
- Sackler School of Medicine, Tel-Aviv University, 35th Klatshkin st., Tel-Aviv, Israel, 6997801
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16
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Li K, Cui M, Zhang K, Liang K, Liu H, Zhai S. Treatment of acute pulmonary embolism using rheolytic thrombectomy. EUROINTERVENTION 2021; 17:e158-e166. [PMID: 32863245 PMCID: PMC9725013 DOI: 10.4244/eij-d-20-00259] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The AngioJet rheolytic thrombectomy (ART) system can quickly fragment and aspirate thrombi according to Bernoulli's principle. AIMS This retrospective study aimed to evaluate the therapeutic effects of the ART system in treating severe acute pulmonary embolism (APE), including high-risk pulmonary embolism (HR-PE) and intermediate-high-risk pulmonary embolism (IHR-PE). METHODS Forty-four APE patients (21 HR-PE and 23 IHR-PE) were enrolled and underwent pulmonary ART using the 6 Fr Solent Omni AngioJet device. Nineteen patients were diagnosed with APE and lower extremity deep venous thrombosis (LEDVT), and underwent thrombectomy of APE and LEDVT simultaneously using ART. All patients also received local thrombolysis with urokinase. RESULTS The results showed that the mean length of stay in intensive care units was 2.4±1.9 days. Significant improvements in clinical, haemodynamic and angiographic parameters were observed in both groups; the improvements in shock index, PaO2, and angiographic parameters were more obvious in the IHR-PE group. Six of the 44 patients died in hospital. During the follow-up, 35 of 38 patients were functioning well and no recurrence of APE was observed. CONCLUSIONS Pulmonary ART plus local thrombolysis of the pulmonary artery for HR-PE or IHR-PE is feasible and appears to be safe. Further studies are warranted to investigate comparative efficacy compared to existing treatments.
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Affiliation(s)
- Kun Li
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Mingzhe Cui
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Kewei Zhang
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Kai Liang
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Heng Liu
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Shuiting Zhai
- Department of Vascular and Endovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou University People's Hospital, 7 Weiwu Road, Zhengzhou, Henan, 450003, China
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17
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Shen J, Zhou M, Shao W, Dai H. Treatment challenges in patients with early acute massive pulmonary thrombosis embolism (PTE) after lung cancer surgery: A case report. Medicine (Baltimore) 2021; 100:e25371. [PMID: 33832122 PMCID: PMC8036128 DOI: 10.1097/md.0000000000025371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/11/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Early acute massive pulmonary thrombosis embolism (PTE) after lung cancer surgery is one of the most fatal surgical complications. It is often accompanied by shock and hypotension, with high mortality rate. Due to surgical wounds, patients with early acute massive PTE after lung cancer surgery have a high risk of thrombolytic bleeding, which renders treatment more challenging and there is currently no standard protocol on how to safely and effectively treat these patients in the clinic. PATIENT CONCERNS A 66-year-old woman after video-assisted thoracoscopic surgery for lung cancer, experienced sudden severe dyspnea, shock and hypotension with high D-Dimer, changed electrocardiogram (ECG), right ventricular dilatation, severe tricuspid regurgitation, and raised pulmonary arterial pressure on ultrasonic cardiogram (UCG), thromboses found on Ultrasonography of lower extremity vein. DIAGNOSIS Because of her clinical manifestations and results of bedside auxiliary examinations, the patient was finally diagnosed with acute high-risk PTE after lung cancer surgery. INTERVENTIONS 1.5 hours after onset of symptoms, thrombolysis using a continuous micropump infusion of 20,000 units/kg urokinase into the peripheral vein for 2 hours was initiated for this patient. OUTCOMES The patient died of massive hemorrhage after thrombolysis. LESSONS Treatment for patients with early acute PTE after lung cancer surgery is challenging due to a high risk of thrombolytic bleeding at the surgical site. Real-time monitoring of vital signs during thrombolysis and catheter-directed thrombolysis are recommended for these patients, in order to use the minimum drug dosage for quick curative effects and a low risk of bleeding.
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Affiliation(s)
| | - Mi Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weihua Shao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyun Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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18
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2083] [Impact Index Per Article: 694.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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19
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Becattini C, Cimini LA, Carrier M. Challenging anticoagulation cases: A case of pulmonary embolism shortly after spontaneous brain bleeding. Thromb Res 2021; 200:41-47. [PMID: 33529872 DOI: 10.1016/j.thromres.2021.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 12/31/2022]
Abstract
Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
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20
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Gangaraju R, Klok FA. Advanced therapies and extracorporeal membrane oxygenation for the management of high-risk pulmonary embolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:195-200. [PMID: 33275707 PMCID: PMC7727511 DOI: 10.1182/hematology.2020000167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Affiliation(s)
- Radhika Gangaraju
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; and
| | - Frederikus A. Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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21
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Massive pulmonary embolism in patients with extreme bleeding risk: a case series on the successful use of ultrasound-assisted, catheter directed thrombolysis in a district general hospital. J Thromb Thrombolysis 2020; 51:1120-1126. [PMID: 32886243 PMCID: PMC8084778 DOI: 10.1007/s11239-020-02258-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Massive pulmonary embolism (PE), characterised by profound arterial hypotension, is a life-threatening emergency with a 90-day mortality of over 50%. Systemic thrombolysis can significantly reduce the risk of death or cardiovascular collapse in these patients, by around 50%, but these benefits are offset by a fivefold increased risk of intracranial haemorrhage and major bleeding, which may limit its use in patients at high risk of catastrophic haemorrhage. We describe a case series of 3 patients presenting with massive PE, each with extreme risk of bleeding and contra-indication to systemic thrombolysis, treated successfully with ultrasound-assisted, catheter directed thrombolysis (U-ACDT). Our experience of this novel technique using the EkoSonic Endovascular System (Ekos, BTG, London, UK) on carefully selected patients has demonstrated the potential to improve clinical status in shocked patients, with minimal bleed risk. There have been several clinical studies evaluating the Ekos system. Both the ULTIMA and SEATTLE II studies have shown significant reductions in RV/LV ratio by CT scanning when compared to standard anticoagulation in patients with intermediate-risk PE, with minimal bleeding complications. However, there is a pressing need for a randomised trial demonstrating improvement in robust clinical outcomes when comparing U-ACDT to simple anticoagulation. We believe that this case series adds new insight and highlights the potential of catheter directed thrombolysis in this high-risk patient cohort and consideration should be made to its use in cases where systemic thrombolysis is felt to be too high risk.
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22
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Araszkiewicz A, Kurzyna M, Kopeć G, Roik M, Darocha S, Pietrasik A, Puślecki M, Biederman A, Przybylski R, Stępniewski J, Furdal M, Mularek-Kubzdela T, Pruszczyk P, Torbicki A. Expert opinion on the creating and operating of the regional Pulmonary Embolism Response Teams (PERT). Polish PERT Initiative. Cardiol J 2020; 26:623-632. [PMID: 31970735 DOI: 10.5603/cj.2019.0127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/11/2020] [Accepted: 01/14/2020] [Indexed: 01/20/2023] Open
Abstract
Pulmonary Embolism Response Team (PERT) is a multidisciplinary team established to stratify risk and choose optimal treatment in patients with acute pulmonary embolism (PE). Established for the first time at Massachusetts General Hospital in 2013, PERT is based on a concept combining a Rapid Response Team and a Heart Team. The growing role of PERTs in making individual therapeutic decisions is identified, especially in hemodynamically unstable patients with contraindications to thrombolysis or with co-morbidities, as well as in patients with intermediate-high risk in whom a therapeutic decision may be difficult. The purpose of this document is to define the standards of PERT under Polish conditions, based on the experience of teams already operating in Poland, which formed an agreement called the Polish PERT Initiative. The goals of Polish PERT Initiative are: improving the treatment of patients with PE at local, regional and national levels, gathering, assessing and sharing data on the effectiveness of PE treatment (including various types of catheter-directed therapy), education on optimal treatment of PE, creating expert documents and supporting scientific research, as well as cooperation with other communities and scientific societies.
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Affiliation(s)
- Aleksander Araszkiewicz
- 1st Department of Cardiology, University of Medical Sciences,Poznan, Poland, Dluga 1/2, 61-848 Poznan, Poland.
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology European Health Centre Otwock, Medical Centre for Postgraduate Education, Otwock, Poland
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland, Poland
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology European Health Centre Otwock, Medical Centre for Postgraduate Education, Otwock, Poland
| | - Arkadiusz Pietrasik
- Department and Faculty of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue and Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Jakub Stępniewski
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Michał Furdal
- Department of Cardiology, Provincial Specialist Hospital, Wroclaw, Poland
| | - Tatiana Mularek-Kubzdela
- 1st Department of Cardiology, University of Medical Sciences,Poznan, Poland, Dluga 1/2, 61-848 Poznan, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology European Health Centre Otwock, Medical Centre for Postgraduate Education, Otwock, Poland
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23
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Acute treatment of venous thromboembolism. Blood 2020; 135:305-316. [PMID: 31917399 DOI: 10.1182/blood.2019001881] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
All patients with venous thromboembolism (VTE) should receive anticoagulant treatment in the absence of absolute contraindications. Initial anticoagulant treatment is crucial for reducing mortality, preventing early recurrences, and improving long-term outcome. Treatment and patient disposition should be tailored to the severity of clinical presentation, to comorbidities, and to the potential to receive appropriate care in the outpatient setting. Direct oral anticoagulants (DOACs) used in fixed doses without laboratory monitoring are the agents of choice for the treatment of acute VTE in the majority of patients. In comparison with conventional anticoagulation (parenteral anticoagulants followed by vitamin K antagonists), these agents showed improved safety (relative risk [RR] of major bleeding, 0.61; 95% confidence interval [CI], 0.45-0.83) with a similar risk of recurrence (RR, 0.90; 95% CI, 0.77-1.06). Vitamin K antagonists or low molecular weight heparins are still alternatives to DOACs for the treatment of VTE in specific patient categories such as those with severe renal failure or antiphospholipid syndrome, or cancer, respectively. In addition to therapeutic anticoagulation, probably less than 10% of patients require reperfusion by thrombolysis or interventional treatments; those patients are hemodynamically unstable with acute pulmonary embolism, and a minority of them have proximal limb-threatening deep vein thrombosis (DVT). The choice of treatment should be driven by the combination of evidence from clinical trials and by local expertise. The majority of patients with acute DVT and a proportion of selected hemodynamically stable patients with acute pulmonary embolism can be safely managed as outpatients.
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24
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Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis. Sci Rep 2020; 10:8870. [PMID: 32483219 PMCID: PMC7264327 DOI: 10.1038/s41598-020-65697-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/09/2020] [Indexed: 01/20/2023] Open
Abstract
Treatment options for chronic thromboembolic pulmonary hypertension (CTEPH) that is not amenable to thromboendarterectomy or is recurrent/persistent after thromboendarterectomy (inoperable CTEPH) include pulmonary vasodilators or balloon pulmonary angioplasty (BPA). We compared efficacy and safety outcomes of BPA with or without pulmonary vasodilators to pulmonary vasodilator therapy alone in patients with inoperable CTEPH. Observational and randomized trial data reporting outcomes for >5 patients with inoperable CTEPH were sought. Single-arm random effects meta-analyses were performed. The primary outcome was change in six-minute walk distance (6MWD). Secondary outcomes included safety; World Health Organization functional class (WHO FC); and change in mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index. Thirty-four studies with 1604 patients were eligible for analyses. Both treatments resulted in significant improvement in 6MWD (71.0 meters, 95% CI: 47.4–94.5 meters with BPA versus 47.8 meters, 95% CI: 34.5–61.2 meters with pulmonary vasodilators), PVR [−3.1 Wood Units (WU), 95% CI: −4.9 to −1.4 WU versus −1.6 WU, 95% CI: −2.4 to −0.8 WU] and mPAP (−14.8 mmHg, 95% CI: −18.2 to −11.5 mmHg versus −4.9 mmHg, 95% CI: −6.9 to −2.8 mmHg). Cardiac index was similar and most patients were WHO FC II and III after their respective interventions. More complications occurred in the BPA arm. In conclusion, BPA and pulmonary vasodilators both improve 6MWD and hemodynamics in patients with inoperable CTEPH. While BPA may offer greater functional and hemodynamic improvements, this technique carries the accompanying risks of an invasive procedure.
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25
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Kaplovitch E, Shaw JR, Douketis J. Thrombolysis in Pulmonary Embolism: An Evidence-Based Approach to Treating Life-Threatening Pulmonary Emboli. Crit Care Clin 2020; 36:465-480. [PMID: 32473692 DOI: 10.1016/j.ccc.2020.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute pulmonary embolism (PE) is associated with high in-hospital morbidity and mortality, both via cardiorespiratory decompensation and the bleeding complications of treatment. Thrombolytic therapy can be life-saving in those with high-risk PE, but requires careful patient selection. Patients with PE and systemic arterial hypotension ("massive PE") should receive thrombolytic therapy unless severe contraindications are present. Patients with PE and right ventricular dysfunction/injury, but without hypotension ("submassive PE"), should be considered for thrombolysis on a case-by-case basis, considering bleeding risk, cardiac biomarkers, echocardiography, and most importantly, clinical status.
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Affiliation(s)
- Eric Kaplovitch
- Department of Medicine, University Health Network and Sinai Health System, University of Toronto, 585 University Avenue, 7th Floor, Room 739, Toronto, Ontario M5G 2N2, Canada.
| | - Joseph R Shaw
- Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada
| | - James Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, 50 Charlton Avenue East, F:403, Hamilton, Ontario L8N 4A6, Canada
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26
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Wu H, Cao H, Song Z, Xu X, Tang M, Yang S, Liu Y, Qin L. Rivaroxaban treatment for young patients with pulmonary embolism (Review). Exp Ther Med 2020; 20:694-704. [PMID: 32742315 PMCID: PMC7388139 DOI: 10.3892/etm.2020.8791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/17/2020] [Indexed: 12/16/2022] Open
Abstract
Pulmonary embolism (PE) is a serious, life-threatening condition that affects young populations (>18 and <50 years old, according to most literature reviews) with improved recognition of its clinical manifestations and the widespread use of sensitive imaging techniques, PE is increasingly diagnosed in younger patients. At present, there is limited understanding of the clinical features and adequate anticoagulant treatment options for this population. Most studies to date have yet to demonstrate significant differences in PE pathophysiology or symptoms between young and elderly patients. Although the overall incidence of PE is lower in young populations compared with elderly patients, important risk factors also apply for young patients. Hereditary thrombophilia is common and is a major cause of PE in younger patients. Immobilization, trauma, obesity, smoking and infection are also becoming increasingly frequent in young patients with PE. Among female patients, oral contraceptive use, pregnancy and postpartum status are predominant risk factors underlying PE. Rivaroxaban is a direct oral anticoagulant with a rapid onset of action that is associated with less drug-drug interactions compared with other therapies. Because the drug is administered at fixed doses with no requirement for routine coagulation monitoring, it is becoming an attractive option for anticoagulation treatment in young patients with PE. Therefore, the present literature review focuses on the clinical characteristics of PE and rivaroxaban therapy in younger patients.
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Affiliation(s)
- Haidi Wu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Hongyan Cao
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Zikai Song
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Xiaoyan Xu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Minglong Tang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Shuo Yang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Yang Liu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ling Qin
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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27
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Ruzsa Z, Vámosi Z, Berta B, Nemes B, Tóth K, Kovács N, Zima E, Becker D, Merkely B. Catheter directed thrombolytic therapy and aspiration thrombectomy in intermediate pulmonary embolism with long term results. Cardiol J 2020; 27:368-375. [PMID: 32329040 DOI: 10.5603/cj.a2020.0060] [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] [Received: 12/02/2019] [Revised: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Catheter directed thrombolysis (CDT) and thrombectomy represent well established techniques for the treatment of intermediate pulmonary embolism (IPE). The long-term effect of catheter directed thrombolysis of IPE is unknown. METHODS Clinical, interventional and echocardiographic data from 80 consecutive patients with IPE who were treated with CDT were evaluated. Primary end-points were technical success and major adverse events. Secondary end-points were cardiovascular mortality, all-cause mortality, clinical success, rate of bleeding complications, improvement in pulmonary pressure and echocardiography parameters. CDT completed with alteplase (10 mg bolus and 1 mg/h maintenance dose) through a pig-tail catheter for 24 h. After 24 h, control pulmonary angiography was performed. RESULTS In total, 80 patients with a mean age of 59.0 ± 16.8 years were treated. CDT was successful after the first post-operative day in 72 (90%) patients, but thrombus aspiration and fragmentation was performed due to failed thrombolysis in 8 (10%) patients. Final technical and clinical success was reached in 79 (98.8%) and 77 (96.3%) patients, respectively. The mean CDT time in IPE was 27.8 ± 9.6 h. Invasive pulmonary pressure dropped from 57.5 ± 16.7 to 38.9 ± 13.5 (p < 0.001). A caval filter was implanted in 4 (5%) patients. The 1-year major adverse events and cardiovascular mortality rate was 4.0% and 1.4%, respectively. Access site complications (6 major and 6 minor) were encountered in 12 (16.2%) patients. CONCLUSIONS Catheter directed thrombolysis in submassive pulmonary embolism had excellent results. However, additional mechanical thrombectomy was necessary in some patients to achieve good clinical outcomes.
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Affiliation(s)
- Zoltan Ruzsa
- Cardiac and Vascular Center, Semmelweis University, Városmajor str 68, 1122 Budapest, Hungary.
| | - Zoltan Vámosi
- Bács-Kiskun County Hospital, Invasive Cardiology Department, Teaching Hospital of Szent-Györgyi Albert Medical University, Kecskemét, Hungary
| | - Balázs Berta
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - Balázs Nemes
- Cardiac and Vascular Center, Semmelweis University, Városmajor str 68, 1122 Budapest, Hungary
| | - Károly Tóth
- Bács-Kiskun County Hospital, Invasive Cardiology Department, Teaching Hospital of Szent-Györgyi Albert Medical University, Kecskemét, Hungary
| | - Nándor Kovács
- Bács-Kiskun County Hospital, Invasive Cardiology Department, Teaching Hospital of Szent-Györgyi Albert Medical University, Kecskemét, Hungary
| | - Endre Zima
- Cardiac and Vascular Center, Semmelweis University, Városmajor str 68, 1122 Budapest, Hungary
| | - Dávid Becker
- Cardiac and Vascular Center, Semmelweis University, Városmajor str 68, 1122 Budapest, Hungary
| | - Béla Merkely
- Cardiac and Vascular Center, Semmelweis University, Városmajor str 68, 1122 Budapest, Hungary
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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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Pillus D, Bruno E, Farcy D, Vilke GM, Childers R. Systematic Review: The Role of Thrombolysis in Intermediate-Risk Pulmonary Embolism. J Emerg Med 2019; 57:517-522. [PMID: 31477311 DOI: 10.1016/j.jemermed.2019.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/15/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND This systemic review provides practicing emergency physicians updated information about the role of thrombolysis in the treatment of intermediate-risk pulmonary embolism. METHODS A PubMed literature search from January 1, 2005 to December 31, 2018 was conducted and limited to human clinical trials written in English with relevant keywords. High-quality studies were identified and then underwent a structured review. Recommendations are made based on the literature review. RESULTS Sixty-three articles met criteria for rigorous review, of which 13 were appropriate for citation in this review. Of these 13, there were 6 prospective studies and 7 retrospective studies. CONCLUSIONS Thrombolysis, either catheter-directed or systemic, is a treatment option in the management of patients with intermediate-risk pulmonary embolism and a high likelihood of clinical deterioration. Each method of thrombolysis carries risks and benefits. Based on the available evidence, transfer to a facility for the purpose of catheter-directed thrombolysis is not recommended.
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Affiliation(s)
- David Pillus
- Department of Emergency Medicine, University of Tennessee, Nashville, Tennessee
| | - Eric Bruno
- Department of Emergency Medicine, University of Tennessee, Nashville, Tennessee
| | - David Farcy
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego Health, San Diego, California
| | - Richard Childers
- Department of Emergency Medicine, University of California, San Diego Health, San Diego, California
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30
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[What are the indications and options for vascular reperfusion in the acute phase of pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e53-e58. [PMID: 31585780 DOI: 10.1016/j.rmr.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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31
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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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32
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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33
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Dy RV, Patel S, Burns K, Mador MJ. Right Heart Thrombi in Pulmonary Embolism, Association of Pulmonary Embolism with Acute Exacerbations of Chronic Obstructive Pulmonary Disease, and Catheter-directed Therapies for Acute Pulmonary Embolism. Am J Respir Crit Care Med 2019; 196:1213-1216. [PMID: 28853904 DOI: 10.1164/rccm.201704-0719rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Rajany V Dy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University at Buffalo, State University of New York
| | - Sumit Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University at Buffalo, State University of New York
| | - Ken Burns
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University at Buffalo, State University of New York
| | - M Jeffery Mador
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University at Buffalo, State University of New York
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34
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Liew J, Stevens J, Slatore C. Refractory Hypoxemia in a Patient with Submassive Pulmonary Embolism and an Intracardiac Shunt: A Case Report and Review of the Literature. Perm J 2018; 22:17-061. [PMID: 29616915 DOI: 10.7812/tpp/17-061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acute pulmonary embolism is the third leading cause of cardiovascular death. Management options include anticoagulation with or without thrombolysis. Concurrent persistent hypoxemia should be a clue to the existence of an intracardiac shunt. CASE PRESENTATION A 46-year-old man experienced acute hypoxemic respiratory failure requiring mechanical ventilation after anesthesia induction for elective hip arthroplasty. He was found to have submassive bilateral pulmonary emboli with acute right ventricular dysfunction and a coexisting patent foramen ovale with right-to-left shunt. He remained profoundly hypoxemic despite catheter-directed thrombolysis. He underwent surgical embolectomy with partial endarterectomy, resulting in clinical improvement. DISCUSSION The management of acute submassive pulmonary embolism is undertaken on an individualized basis because of the wide spectrum of clinical presentations. In this report we review the literature and discuss the evidence behind the management of cases of acute pulmonary embolism complicated by hypoxemia from a patent foramen ovale. In a case of acute pulmonary embolism complicated by refractory hypoxemia from an intracardiac shunt, adjunctive therapies in addition to anticoagulation and thrombolysis must be considered.
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Affiliation(s)
- Jean Liew
- Fellow Physician in the Division of Rheumatology in the Department of Medicine at the University of Washington in Seattle.
| | - Janelle Stevens
- Fellow Physician in the Division of Pulmonary and Critical Care Medicine in the Department of Medicine at Oregon Health & Science University in Portland.
| | - Christopher Slatore
- Associate Professor in the Section of Pulmonary and Critical Care Medicine in the Veterans Affairs Portland Health Care System in OR, and an Attending Physician in the Division of Pulmonary and Critical Care Medicine in the Department of Medicine at Oregon Health & Science University in Portland.
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Patel N, Bajaj NS. Meta-analyses: How to critically appraise them? J Nucl Cardiol 2018; 25:1598-1600. [PMID: 28447280 PMCID: PMC5658261 DOI: 10.1007/s12350-017-0898-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Nirav Patel
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
- Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Philippot Q, Roche A, Goyard C, Pastré J, Planquette B, Meyer G, Sanchez O. Prise en charge de l'embolie pulmonaire grave en réanimation. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L'embolie pulmonaire (EP) grave, définie par la présence d’un état de choc, est à l'origine d'une mortalité importante. L'objectif de cette mise au point est de synthétiser les dernières avancées et recommandations concernant la prise en charge des formes graves d'EP. La stratification du risque individuel de mortalité précoce permet d'apporter une stratégie diagnostique et thérapeutique optimisée pour chaque patient. Le traitement symptomatique consiste essentiellement en la prise en charge de l'état de choc. L'anticoagulation curative par héparine non fractionnée est réservée aux patients hémodynamiquement instables. Chez ces patients à haut risque, la thrombolyse systémique diminue la mortalité et le risque de récidive d'EP. Chez les patients à risque intermédiaire élevé, la thrombolyse systémique à dose standard diminue le risque de choc secondaire mais sans impact sur la mortalité globale. La thrombolyse est donc réservée aux patients à risque intermédiaire élevé présentant secondairement un état de choc. L'embolectomie chirurgicale reste indiquée en cas de contre-indication absolue à la thrombolyse ou en cas d'échec de celle-ci. Le positionnement dans l'algorithme thérapeutique de l'assistance extracorporelle et des techniques percutanées de revascularisation reste à définir. Leurs indications doivent donc être discutées dans des centres experts après une concertation multidisciplinaire incluant pneumologues, cardiologues, réanimateurs, radiologues interventionnels et chirurgiens cardiaques.
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Treatment of high- and intermediate-risk pulmonary embolism using the AngioJet percutaneous mechanical thrombectomy system in patients with contraindications for thrombolytic treatment - a pilot study. Wideochir Inne Tech Maloinwazyjne 2018; 13:233-242. [PMID: 30002757 PMCID: PMC6041588 DOI: 10.5114/wiitm.2018.75848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/02/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Intravenous thrombolysis is the treatment of choice in patients presenting with high- and intermediate-risk pulmonary embolism. The role of percutaneous mechanical pulmonary thrombectomy (PMPT) is not fully established, although selected patients can be managed with this method. Aim This open-label single-centre prospective pilot study was aimed at assessing the feasibility of PMPT for the treatment of severe pulmonary embolism in a Polish hospital. We also evaluated the safety and efficacy of such management. Material and methods We managed 7 patients, aged 52.7 ±16.6 years, presenting with high- and intermediate-risk pulmonary embolism (4 patients with class 5 and one patient with class 4 of the Pulmonary Embolism Severity Index), with occlusion of at least 2 lobar arteries and contraindications for thrombolysis. Percutaneous mechanical pulmonary thrombectomy was performed using the AngioJet system. Results It was possible to introduce the thrombectomy system to the pulmonary arteries in all patients. The procedure was successful in 6 patients (technical success rate: 85.7%). Two (28.6%) patients died during the hospital stay, one patient with unsuccessful thrombectomy and the other due to pneumonia. In all survivors control echocardiography demonstrated normalised function of the right ventricle. Also, dyspnoea disappeared and blood gas parameters normalised. There was no recurrent thromboembolism during 3-14 months of follow-up. Conclusions In the Polish setting, in selected patients, management of high- and intermediate-risk pulmonary embolism with PMPT is technically feasible. Such treatment is relatively safe and effective. It can be an alternative to standard management, especially in patients with contraindications for fibrinolysis or surgical embolectomy.
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Konstantinides SV, Barco S. Prevention of early complications and late consequences after acute pulmonary embolism: Focus on reperfusion techniques. Thromb Res 2018; 164:163-169. [DOI: 10.1016/j.thromres.2017.05.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/27/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
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Kabrhel C, Ali A, Choi JG, Hur C. Systemic Thrombolysis, Catheter-Directed Thrombolysis, and Anticoagulation for Intermediate-risk Pulmonary Embolism: A Simulation Modeling Analysis. Acad Emerg Med 2017. [PMID: 28650086 DOI: 10.1111/acem.13242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Decision making around the use of thrombolysis for patients with intermediate-risk (submassive) pulmonary embolism (PE) remains challenging. Studies indicate favorable clinical outcomes with systemic thrombolytics (intravenous tissue plasminogen activator [IV tPA]), but the risk of major bleeding and hemorrhagic stroke is a deterrent. Catheter-directed thrombolysis (CDT) may be a preferable strategy, as it has been shown to have a lower risk of bleeding than systemic thrombolysis. However, a three-arm randomized control study comparing IV tPA, CDT, and anticoagulation alone, with long-term follow up, would be costly and is unlikely to be performed. The aim of this study was to use decision modeling to quantitatively estimate the differences between the three strategies. METHODS We created an individual-level state-transition model to simulate long-term outcomes of a hypothetical patient cohort treated with IV tPA, CDT, or anticoagulation alone. Our model incorporated clinical randomized controlled trial and longitudinal study data to inform patient characteristics and outcomes specific to each study arm. The base case was a 65-year-old patient. Additionally, we utilized preliminary data published by the Pulmonary Embolism Response Team at the Massachusetts General Hospital. Variance in model inputs was addressed with deterministic and probabilistic sensitivity analyses. Our primary endpoint was quality-adjusted life-years (QALYs). Secondary endpoints included total cost and incremental cost-effectiveness ratios (ICERs). RESULTS Catheter-directed thrombolysis (mean, 95% confidence interval [CI] = 7.388 [7.381-7.396] QALYs) resulted in the most long-term utility for eligible patients compared to anticoagulation alone (7.352 [7.345-7.360] QALYs) or IV tPA (7.343 [7.336-7.351] QALYs). Patients receiving CDT had an elevated risk of hemorrhagic stroke in comparison to anticoagulation alone; however, patients treated with anticoagulation alone were more likely to experience recurrent PE associated adverse outcomes. Results were stable with sensitivity analyses varying age and sex. Our probabilistic sensitivity analysis assessing joint variance predicts CDT to be the most effective strategy, when measured by mean QALYs, in 98.4% of runs, while systemic thrombolysis was favored over anticoagulation alone 34.4% of the time. The ICER of CDT compared to anticoagulation was $317,042 per QALY gained. CONCLUSION In our model, for those eligible, CDT results in the largest number of QALYs for patients with intermediate-risk PE, although it is relatively expensive and the absolute difference in QALYs between anticoagulation alone and CDT is small. Future studies that provide data on longitudinal quality-of-life outcomes of patients treated for PE and characteristics of CDT would be beneficial to augment model inputs, inform assumptions, and validate results.
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Affiliation(s)
- Christopher Kabrhel
- Center for Vascular Emergencies; Department of Emergency Medicine; Massachusetts General Hospital; Boston MA
- Harvard Medical School; Boston MA
| | - Ayman Ali
- Gastrointestinal Unit; Massachusetts General Hospital; Boston MA
- Institute for Technology Assessment; Massachusetts General Hospital; Boston MA
| | - Jin G. Choi
- Gastrointestinal Unit; Massachusetts General Hospital; Boston MA
- Institute for Technology Assessment; Massachusetts General Hospital; Boston MA
| | - Chin Hur
- Gastrointestinal Unit; Massachusetts General Hospital; Boston MA
- Institute for Technology Assessment; Massachusetts General Hospital; Boston MA
- Harvard Medical School; Boston MA
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Abstract
Heart failure (HF) remains the leading cause of hospitalization in older adults and is associated with increased morbidity and mortality despite the use of guideline-directed medical therapy. There has been tremendous progress in the development of novel transcatheter and interventional therapies for HF over the past decade. The evolution of structural heart disease interventions and interventional HF has led to a multidisciplinary heart team approach in the management of HF patients. Careful selection of the appropriate patient population and end points in future randomized controlled trials will be crucial to demonstrate the potential efficacy of the novel interventional HF therapies.
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Affiliation(s)
- Dhaval Kolte
- Division of Cardiovascular Medicine, Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Jinnette Dawn Abbott
- Division of Cardiovascular Medicine, Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Herbert D Aronow
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA.
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Barco S, Konstantinides SV. Catheter-directed thrombolysis for acute pulmonary embolism: Where do we stand? Lung India 2017; 34:221-222. [PMID: 28474644 PMCID: PMC5427746 DOI: 10.4103/lungindia.lungindia_115_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece E-mail:
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