Safety and efficacy of ultrasound-accelerated catheter-directed lytic therapy in acute pulmonary embolism with and without hemodynamic instability

Episode Care Costs Following Catheter-Directed Reperfusion Therapies for Pulmonary Embolism: A Literature-Based Comparative Cohort Analysis

This analysis aimed to estimate 30-day episode care costs associated with 3 contemporary endovascular therapies indicated for treatment of pulmonary embolism (PE). Systematic literature review was used to identify clinical research reporting costs associated with invasive PE care and outcomes for ultrasound-accelerated thrombolysis (USAT), continuous-aspiration mechanical thrombectomy (CAMT), and volume-controlled-aspiration mechanical thrombectomy (VAMT). Total episode variable care costs were defined as the sum of device costs, variable acute care costs, and contingent costs. Variable acute care costs were estimated using methodology sensitive to periprocedural and postprocedural resource allocation unique to the 3 therapies. Contingent costs included expenses for thrombolytics, postprocedure bleeding events, and readmissions through 30 days. Through February 28, 2023, 70 sources were identified and used to inform estimates of 30-day total episode variable costs. Device costs for USAT, CAMT, and VAMT were the most expensive single component of total episode variable costs, estimated at $5,965, $10,279, and $11,901, respectively. Costs associated with catheterization suite utilization, intensive care, and hospital length of stay, along with contingent costs, were important drivers of total episode costs. Total episode variable care costs through 30 days were $19,146, $20,938, and $17,290 for USAT, CAMT, and VAMT, respectively. In conclusion, estimated total episode care costs after invasive treatment for PE are heavily influenced by device expense, in-hospital care, and postacute care complications. Regardless of device cost, strategies that avoid thrombolytics, reduce the need for intensive care unit care, shorten length of stay, and reduce postprocedure bleeding and 30-day readmissions contributed to the lowest episode costs.

Implementing a Pediatric Pulmonary Embolism Response Team Model: An Institutional Experience

Pulmonary embolism is increasing in prevalence among pediatric patients; although still rare, it can create a significant risk for morbidity and death within the pediatric patient population. Pulmonary embolism presents in various ways depending on the patient, the size of the embolism, and the comorbidities. Treatment decisions are often driven by the severity of the presentation and hemodynamic effects; severe presentations require more invasive and aggressive treatment. We describe the development and implementation of a pediatric pulmonary embolism response team designed to facilitate rapid, multidisciplinary, data-driven treatment decisions and management.

Urokinase versus Alteplase in Patients with Intermediate-High-Risk Pulmonary Embolism Treated with Ultrasound-Accelerated Endovascular Thrombolysis

BACKGROUND

Ultrasound-accelerated thrombolysis (USAT) is a safe and effective treatment for patients with intermediate-high-risk pulmonary embolism (PE). In all studies investigating USAT in the setting of PE, the recombinant tissue-plasminogen activator (rt-PA) alteplase or actilyse was used. Currently, there is a shortage of alteplase (Alteplase, Boehringer Ingelheim) in Europe. It is unknown whether the efficacy of urokinase (UK) is comparable with alteplase for USAT in patients with PE.

METHODS

Patients with intermediate-high-risk PE undergoing USAT with urokinase and alteplase were included in this study. One-to-one nearest neighbour matching was performed to account for baseline differences. We identified one patient treated with USAT and UK (n = 9) for each patient treated with USAT and alteplase (n = 9).

RESULTS

A total of 56 patients underwent USAT. The treatment was successful in all patients. The propensity score matched the identified nine pairs of patients. There were no statistically significant differences in the change in right ventricle-to-left ventricle (RV/LV) ratio (0.4 ± 0.3 versus 0.5 ± 0.4, p = 0.54), systolic pulmonary artery pressure (17.3 ± 8.0 versus 18.1 ± 8.1, p = 0.17), or improvement of RV function (5.8 ± 3.8 versus 5.1 ± 2.6, p = 1.0). The complication rates were comparable (11% in both groups, p = 0.55). There were no deaths in hospital or during 90 days in either group.

CONCLUSIONS

In this case-matched comparison, the short-term clinical and echocardiographic outcomes showed comparable results between USAT-UK and USAT-rt-PA.

An Update on the Management of Acute High-Risk Pulmonary Embolism

Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.

Clinical outcomes of very elderly patients treated with ultrasound-assisted catheter-directed thrombolysis for pulmonary embolism: a systematic review

Pulmonary embolism (PE) is a significant cause of death in the very elderly (≥ 75 years) population. Ultrasound-assisted catheter-directed thrombolysis (USCDT) emerges to improve thrombolysis safety and efficacy. However, outcomes in very elderly patients are unknown, as randomized controlled trials exclude this population. Recently, we demonstrated acute kidney injury (AKI) and ischemic hepatitis in an octogenarian intermediate-risk PE patient treated with USCDT. Considering the lack of evidence, we undertook a systematic review to evaluate the clinical outcomes in very elderly PE patients treated with USCDT. We searched for very elderly PE patients treated with USCDT from 2008 to 2019. Additionally, we conducted another systematic review without age restriction to update previous evidence and compare both populations. We also did an exploratory analysis to determine if thrombolysis was followed based on current guidelines or impending clinical deterioration factors. We identified 18 very elderly patients (age 79.2, 75-86), mostly female and with intermediate-risk PE. We found an intracranial hemorrhage (ICH), and a right pulmonary artery rupture. Additionally, two significant bleedings complicated with transient AKI, and one case of AKI and ischemic hepatic injury. The patients who survived all had clinical and echocardiographic in-hospital improvement. Despite low rt-PA doses, ICH and major bleeding remain as feared complications. Thrombolysis decision was driven by impending clinical deterioration factors instead of international guideline recommendations. Our data do not suggest prohibitive risk associated with USCDT in very elderly intermediate and high-risk PE patients. Despite long-term infusions and right ventricular dysfunction, AKI and ischemic hepatic injury were infrequent.

Short-term Cost Comparison of Systemic Heparin Therapy vs. Catheter Directed Thrombolysis for the Treatment of Massive and Submassive Pulmonary Embolism with Long-Term Chronic Pulmonary Hypertension Cost Model

INTRODUCTION

Pulmonary embolism (PE) is a significant disease process that affects an estimated 117 cases per 100,000 person-years. Chronic pulmonary hypertension (CPH) is a long-term complication associated with acute PE which has a significant cost to treat, ranging from $98,000-117,000.

METHODS

A retrospective chart review of 341 patients from January 2011 to November 2018 who presented with massive or submassive PE and were treated with either systemic heparin therapy or catheter directed thrombolysis (CDT). The results of the short-term cost analysis and pulmonary hypertension rates from data collected was then used in a long-term cost model using a standardized 100 patient model.

RESULTS

Treatment with CDT resulted in fewer bleeding complications (4.2 percent vs. 13.8 percent, p=0.005), a shorter length of stay, a greater percentage of patients returning to their prior living conditions (89.0 percent vs. 79.3 percent, p=0.042), and a lower rate of chronic pulmonary hypertension at 12 months (6.3 percent vs. 15.9 percent, p=0.030) than those treated with systemic heparin. The expense of treatment utilizing CDT was greater than those undergoing systemic heparin treatment with a difference of approximately $31,000 (p=0.001) though our cost model showed the heparin group to have a higher cost over time.

CONCLUSIONS

For patients with massive or submassive PE, this study demonstrated a significant long-term cost savings and improved outcomes for patients treated with catheter directed thrombolysis when compared to systemic heparin administration.

First year experience of a pulmonary embolism response team with comparisons of outcomes between catheter directed therapy versus standard anticoagulation

Objectives: The Pulmonary Embolism Response Team (PERT) model is now widely adopted in many institutions to provide multidisciplinary care for patients with acute pulmonary embolism (PE). However, descriptive experiences of PERT operations and studies on clinical outcomes remain limited.Methods: We performed a retrospective review of PERT activations at an academic tertiary care center, with secondary aims to study outcomes associated with performing catheter directed therapies (CDT).Results: The intermediate high-risk PE category was most frequent (n = 40, 76.9%) among the 52 total cases evaluated during the study period. There was one in-hospital mortality, associated with hospice admission for a non-PE diagnosis. Six patients (11.5%) experienced a bleeding complication of any severity. Anticoagulation (AC) alone was recommended in 30 patients (57.7%) and CDT was performed in 16 patients (30.8%). There were no significant differences in patient characteristics or disease severity between patients in the AC group versus the CDT group, except for a higher prevalence of malignancy in the AC group (p = 0.037). Patients who underwent CDT demonstrated a lower, albeit non-significant, median intensive care unit (ICU) length of stay (LOS) (3 vs. 4 days, p = 0.34) and hospital LOS (4 vs. 5 days, p = 0.25), as compared to patients receiving AC alone. Bleeding rates were similar between the two groups (6.7% vs. 6.3%, p = 1.0).Conclusions: Adoption of the PERT model at an academic tertiary care center was associated with acceptably low rates of mortality and bleeding, similar to other published studies. Performing CDT in select patients under PERT consultation may be associated with shorter ICU and hospital LOS; however, larger studies are needed to validate this finding.

Nursing Care Practices for Patients With Pulmonary Embolism Undergoing Treatment With Ultrasound-Assisted Thrombolysis: An Integrative Review

BACKGROUND

Pulmonary embolism (PE) remains a common and life-threatening event. The use of ultrasound-assisted thrombolysis (USAT) for the delivery of thrombolytic agents to the clot has developed in the last 10 years. A search yielded no evidence-based practice guidelines for the nursing care of the patient with PE during and post USAT treatment and specifically when using the EKOS machine.

OBJECTIVE

The objective of this integrative review was to explore the literature and web for any information on the use of USAT for adults with PE both during and post treatment. Our goal was to examine nurse-specific practices to develop appropriate protocols.

METHODS

We conducted a search of PubMed, Web of Science, EBSCOhost, CINAHL, Google Scholar, and Google for any guidelines, observational studies, or experimental studies using USAT for PE in adults. Nurse authors independently reviewed the articles using a standardized data coding form. Information abstracted included sample and setting characteristics, access characteristics, medication, sheath removal, compression, and bleeding events.

RESULTS

Twenty-two articles, published in 2008-2019, met the eligibility criteria. Most studies were small retrospective studies at single sites. Variation existed on the clinician, the clinical area for placement, the amount and duration of delivery of medication, and where care was provided during the infusion. Few studies noted sheath removal or compression procedures. Fifteen studies reported 1 fatal, 12 major, 4 moderate, and 36 minor bleeding events at the catheter insertion sites.

CONCLUSION

There is lack of sufficient information for the development of nursing practice guidelines for this new technology.

Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence

Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.

A Randomized Trial of the Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Intermediate-Risk Pulmonary Embolism: The OPTALYSE PE Trial

OBJECTIVES

The aim of this study was to determine the lowest optimal tissue plasminogen activator (tPA) dose and delivery duration using ultrasound-facilitated catheter-directed thrombolysis (USCDT) for the treatment of acute intermediate-risk (submassive) pulmonary embolism.

BACKGROUND

Previous trials of USCDT used tPA over 12 to 24 h at doses of 20 to 24 mg for acute pulmonary embolism.

METHODS

Hemodynamically stable adults with acute intermediate-risk pulmonary embolism documented by computed tomographic angiography were randomized into this prospective multicenter, parallel-group trial. Patients received treatment with 1 of 4 USCDT regimens. The tPA dose ranged from 4 to 12 mg per lung and infusion duration from 2 to 6 h. The primary efficacy endpoint was reduction in right ventricular-to-left ventricular diameter ratio by computed tomographic angiography. A major secondary endpoint was embolic burden by refined modified Miller score, measured on computed tomographic angiography 48 h after initiation of USCDT.

RESULTS

One hundred one patients were randomized, and improvements in right ventricular-to-left ventricular diameter ratio were as follows: arm 1 (4 mg/lung/2 h), 0.40 (24%; p = 0.0001); arm 2 (4 mg/lung/4 h), 0.35 (22.6%; p = 0.0001); arm 3 (6 mg/lung/6 h), 0.42 (26.3%; p = 0.0001); and arm 4 (12 mg/lung/6 h), 0.48 (25.5%; p = 0.0001). Improvement in refined modified Miller score was also seen in all groups. Four patients experienced major bleeding (4%). Of 2 intracranial hemorrhage events, 1 was attributed to tPA delivered by USCDT.

CONCLUSIONS

Treatment with USCDT using a shorter delivery duration and lower-dose tPA was associated with improved right ventricular function and reduced clot burden compared with baseline. The major bleeding rate was low, but 1 intracranial hemorrhage event due to tPA delivered by USCDT did occur.

Meta-Analysis of Catheter Directed Ultrasound-Assisted Thrombolysis in Pulmonary Embolism

Ultrasound-assisted catheter directed thrombolysis (USAT) has been shown to improve hemodynamic function and reduce bleeding complications in patients with acute massive or submassive pulmonary embolism. We performed a meta-analysis to better evaluate the efficacy and safety of USAT. We conducted an extensive literature search in PUBMED, MEDLINE, and EMBASE databases from January 1, 2008 to December 31, 2018. Efficacy outcomes of interest were pulmonary artery systolic pressure, mean pulmonary pressure, ratio of right ventricular to left ventricular diameter, cardiac index, tricuspid annular plane systolic excursion, Miller Index Score, and Qanadli Score. Safety outcomes were in-hospital mortality, long-term mortality, major and minor bleeding complications, and recurrent pulmonary embolism. Meta-analysis was performed using Cochrane Collaboration Review Manager (version 5.1). Effect size was estimated using random effects model, with 95% confidence intervals (CIs). Twenty-eight studies (n = 2,135) met inclusion criteria. Compared with pretreatment parameters, post-USAT was associated with a reduction in the mean Miller Index Score and Qanadli Score by 10.55 (95% CI -12.98 to -8.12) and 15.64 (95% CI -19.08 to -12.20), respectively. Cardiac index and tricuspid annular plane systolic excursion improved by 0.68 L/m² (95% CI 0.49 to 0.87) and 3.68 mm (95% CI 2.43 to 4.93), respectively. Pulmonary artery systolic pressure and mean pulmonary pressure after therapy were reduced by a mean difference of 16.69 mm Hg (95% CI -19.73 to -13.65) and 12.13 mm Hg (95% CI -14.67 to -9.59) respectively. The right ventricular to left ventricular diameter dimension ratio decreased by 0.35 (95% CI -0.40 to -0.30) after therapy. In-hospital mortality in patients who underwent USAT was 2.9%, and total long-term mortality was 4.1%. Major and minor bleeding complications were seen in in 5.4% and 6.0% of patients, respectively. Recurrent events occurred in 0.2% of patients after USAT. In conclusion, USAT is a safe and effective procedure associated with significant hemodynamic and clinical improvement in patients with massive and submassive pulmonary embolism.

Is there an optimal "door to cath time" in the treatment of acute pulmonary embolism with catheter-directed thrombolysis?

Ultrasound assisted catheter-directed thrombolysis (UACT) is a relatively novel approach to treating acute pulmonary embolism (PE). It is an alternative to systemic thrombolysis with good success rates and low reported in-hospital mortality, and low rates of procedure-related major and minor bleeding. Since UACT received FDA approval for the treatment of PE in 2014, there is paucity of data regarding the optimal timing of initiation of the procedure after the initial diagnosis is made. We reviewed the available literature regarding UACT for acute PE and found six studies that included time to procedure. Based on our review, patients may benefit from early (<24-48 h after presentation) rather than delayed (>48 h) initiation. Early initiation of therapy has shown to improve pulmonary arterial pressures, right ventricular (RV) to left ventricular (LV) ratios, with low rates of bleeding and low post procedural and in hospital mortality. However, further studies are required to confirm these findings and establish the appropriate timeline for initiation of UACT.

The implementation of a pulmonary embolism response team in the management of intermediate- or high-risk pulmonary embolism

BACKGROUND

Massive and submassive pulmonary embolism (PE) can be life-threatening. Treatment options include anticoagulation, fibrinolysis, catheter-directed or open surgical thrombus removal, and extracorporeal membrane oxygenation. With increasing patient complexity and advanced therapeutic options, the approach to optimal care for patients with intermediate- to high-risk PE is not clearly established. Multidisciplinary, rapid response teams can optimize risk stratification and expedite management. A PE response team (PERT) composed of specialists from cardiology, vascular surgery, emergency medicine, pulmonary and critical care, interventional radiology, cardiac surgery, hospital medicine, and pharmacy was created at our institution. The team is tasked with evaluating and treating patients with massive and submassive PE by use of a risk stratification and treatment algorithm. We describe our initial experience with this approach.

METHODS

The records of patients treated by the PERT since inception in October 2015 through May 2017 were reviewed (intervention group). The diagnoses codes of the PERT patients were retrieved from the Vizient database. A retrospective control cohort group was created using these specific diagnoses and a matching set of demographics (age, sex), Medicare Severity Diagnosis Related Group, admission severity of illness, and admission risk of mortality. Statistical analysis was performed using the Fisher exact test, the Pearson χ² statistic, Student t-test, and Cochran-Cox approximation. P < .05 was considered significant.

RESULTS

During the time interval, 77 patients with massive or submassive PE were treated by PERT activation; 992 patients included in the control group were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of risk of mortality and severity of illness, and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower intensive care unit stay and overall length of stay. No difference was seen in direct cost between the two groups despite higher use of interventional treatment modalities in the PERT group.

CONCLUSIONS

In our institution, assembly of a dedicated team to treat patients with massive or submassive PE according to a clinical algorithm resulted in expedited treatment and reduced variation of care. Intensive care unit stay and overall length of stay were reduced by this approach, with no impact on direct cost despite the use of advanced modalities of treatment. We believe that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved.

Ultrasound-assisted catheter-directed thrombolysis compared with anticoagulation alone for treatment of intermediate-risk pulmonary embolism

It is unclear if ultrasound-assisted catheter-directed thrombolysis (UACDT) confers benefit over anticoagulation (AC) alone in the management of intermediate-risk ("submassive") pulmonary embolism (PE), defined by evidence of right ventricular (RV) dysfunction in hemodynamically stable patients. This study sought to evaluate any lasting advantage of UACDT on mortality and resolution of RV dysfunction in intermediate-risk PE at a large academic medical center. Adults aged ≤ 86 years admitted with intermediate-risk PE from 2011 to 2016 were retrospectively identified. Patients were excluded if there was a history of cancer, pre-existing pulmonary hypertension, pregnancy or postpartum status, contraindication to AC, or treatment with systemic thrombolysis. Baseline Pulmonary Embolism Severity Index (PESI) scores were computed. Outcomes including length of stay (LOS), bleeding complications, resolution of RV dysfunction, and mortality were compared between patients who received UACDT and those managed with AC alone. A total of 104 patients met inclusion criteria, 65 of whom underwent UACDT. The cohorts had similar PESI scores ( P = 0.45) and no clearly imbalanced confounding variables. There was no significant difference in LOS ( P = 0.11). UACDT was associated with more bleeding complications (exact P = 0.04). Follow-up transthoracic echocardiograms performed in 54 UACDT and 24 AC patients demonstrated similar rates of resolution of RV dysfunction (61% in UACDT patients versus 75% in AC patients, P = 0.25). Overall one-year mortality was approximately 5% in both groups (exact P > 0.99). In this limited retrospective analysis of intermediate-risk PE patients, UACDT treatment was not associated with mortality benefit or increased resolution of RV dysfunction.

Rationale for catheter directed therapy in pulmonary embolism

Pulmonary embolism (PE) is a widespread health concern associated with major morbidity and mortality. Catheter directed therapy (CDT) has emerged as a treatment option for acute PE adding to the current potential options of systemic thrombolysis or anticoagulation. The purpose of this review is to understand the rationale and indications for CDT in patients with PE. While numerous studies have shown the benefits of systemic thrombolysis compared to standard anticoagulation, these are balanced by the increased risk of major bleeding. With this in mind, CDT has the potential to offer the benefits of systemic thrombolysis and in theory, a reduced risk of bleeding. This article will review current treatment guidelines in both massive and submassive PE evaluating both short and long term benefits. The role of CDT will be highlighted, with an emphasis on efficacy and safety.

A pulmonary embolism response team's initial 20 month experience treating 87 patients with submassive and massive pulmonary embolism

Pulmonary Embolism Response Teams (PERTs) have emerged to provide rapid multidisciplinary assessment and treatment of PE patients. However, descriptive institutional experience and preliminary outcomes data from such teams are sparse. PERT activations were identified through a retrospective review. Only confirmed submassive or massive PEs were included in the data analysis. In addition to baseline variables, the therapeutic intervention, length of stay (LOS), in-hospital mortality, and bleeding rate/severity were recorded. A total of 124 PERT activations occurred over 20 months: 43 in the first 10 months and 81 in the next 10. A total of 87 submassive (90.8%) and massive (9.2%) PE patients were included. The median age was 65 (51-75 IQR) years. Catheter-directed thrombolysis (CDT) was administered to 25 patients, systemic thrombolysis (ST) to six, and anticoagulation alone (AC) to 54. The median ICU stay and overall LOS were 6 (3-10 IQR) and 7 (4-14 IQR) days, respectively, with no association with any variables except a brain natriuretic peptide (BNP) >100 pg/mL ( p=0.008 ICU LOS; p=0.047 overall LOS). Twelve patients (13.7%) died in the hospital, nine of whom had metastatic or brain cancer, with a median overall LOS of 13 (11-17 IQR) days. There were five major bleeds: one in the CDT group, one in the ST group, and three in the AC group. Overall, (1) PERT activations increased after the first 10 months; (2) BNP >100 pg/mL was associated with a longer LOS; (3) rates of mortality and bleeding did not correlate with treatment; and (4) the majority of in-hospital deaths occurred in patients with advanced cancer.

Ultrasound Assisted Catheter-Directed Thrombolysis of Acute Pulmonary Embolism: A Review of Current Literature

Pulmonary embolism continues as a very common and also presumably life-threatening disorder. For affected individuals with intermediate- as well as high-risk pulmonary embolism, catheter-based revascularization procedures have developed a possible substitute for systemic thrombolysis or for surgical embolectomy. Ultrasound-assisted catheter-directed thrombolysis is an innovative catheter-based approach; which is the main purpose of the present review article. Ultrasound-assisted catheter-directed thrombolysis is much more efficacious in reversing right ventricular dysfunction as well as dilatation in comparison to anticoagulation alone in individuals at intermediate risk. However, a direct comparison of ultrasound-assisted thrombolysis with systemic thrombolysis or surgical thrombectomy is not available. Ultrasound-assisted thrombolysis with early intrapulmonary thrombolytic bolus could also be successful in high-risk patients, but unfortunately, data from randomized trials is limited. This review article recapitulates existing information on ultrasound-assisted thrombolysis for acute pulmonary embolism.

Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis

OBJECTIVES

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE).

BACKGROUND

The use of CDT for the treatment of acute submassive and massive PE is increasing in frequency. However, its safety and efficacy have not been well elucidated.

METHODS

This study is made of two parts: one is a two-center registry of acute PE patients treated with CDT. The safety outcome evaluated was any major complication including fatal, intracranial (ICH), intraocular, or retroperitoneal hemorrhage or any overt bleeding requiring transfusion or surgical repair. The efficacy outcome was acute change in invasive pulmonary artery systolic pressure (PASP). The second part is a meta-analysis of all contemporary studies that used CDT for PE. Reported outcomes are the same as in the registry, with the addition of right ventricular to left ventricular (RV/LV) ratio change.

RESULTS

In the registry, 137 patients were included (age 59 ± 15, 50% male, 88% submassive PE). ICH occurred in two patients and major complications in 13 (9.4%). PASP decreased post procedure by 19 ± 15 mm Hg (95% CI 16-23). In the meta-analysis, 16 studies were included with 860 patients. Rate of ICH was 0.35% and the major complication rate was 4.65%, most requiring transfusion only. In-hospital mortality was 12.9% in the massive and 0.74% in the submassive group. All studies showed improvement in PASP and/or RV/LV ratio post CDT.

CONCLUSIONS

CDT is associated with a low major complication rate. Randomized studies are needed to evaluate its efficacy relative to anticoagulation alone. © 2017 Wiley Periodicals, Inc.