Interventional therapies for pulmonary embolism

Safety and efficacy of catheter-directed thrombectomy without thrombolysis in acute pulmonary embolism: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to investigate the safety and efficacy of catheter-directed thrombectomy (CDT) without using adjunct thrombolysis as reperfusion therapy to manage intermediate and high-risk pulmonary embolism (PE).

METHODS

A literature search of Ovid MEDLINE, Embase, CiNAHL, Cochrane Library, and Web of Science was conducted from inception to January 2024. Eligible studies reported more than 10 patients treated for acute PE with catheter-directed thrombectomy only, who were over 18 years of age. Primary endpoints were major bleeding, in-hospital mortality, and hemodynamic changes.

RESULTS

Eighteen studies (n = 803) were included for quantitative analysis. The pooled estimate of incidences of in-hospital mortality and major bleeding was 1.8 % (95 % CI 0.009, 0.027) and 2.1 % (95 % CI 0.011, 0.031) respectively. A pooled estimate reported a post-procedural increase in oxygen saturation and systolic blood pressure by 8.96 % (95 % CI: 3.54, 14.38) and 15.02 mmHg (95 % CI 6.35, 23.69) respectively. Post-procedural mean pulmonary artery pressure, right ventricle/left ventricle (RV/LV) ratio, and Miller score were reduced by 10.30 mmHg (95 % CI -14.94, -5.66), 0.29 (95 % CI -0.50, -0.08) and 8.09 (95 % CI -10.70, -5.47) respectively.

CONCLUSION

CDT without adjunctive thrombolysis may lead to improvements in hemodynamic outcomes and exhibits favorable safety profiles. This meta-analysis provides a rationale for lowering the threshold for considering this technique, and ongoing randomized trials will further advance the field to determine optimal managment strategies for intermediate and high-risk acute PE.

Socioeconomic Burden of Pulmonary Embolism in Europe: Shifting Priorities and Challenges for Novel Reperfusion Strategies

In-hospital case fatality related to acute pulmonary embolism (PE) has been falling since the beginning of this century. However, annual incidence rates continue to climb, and an increasing number of PE survivors need long-term follow-up, chronic anticoagulation treatment, and readmission(s) to the hospital. In European countries, median reimbursed hospital costs for acute PE are still moderate compared with the United States but can increase several-fold in patients with comorbidities and those necessitating potentially life-saving reperfusion treatment. The use of catheter-directed treatment (CDT) has constantly increased in the United States since the past decade, and it has now entered a rapid growth phase in Europe as well, estimated to reach an annual penetration rate of up to 31% among patients with intermediate-high- or high-risk PE by 2030. Ongoing randomised controlled trials are currently investigating the clinical efficacy and safety of these devices. In addition, they will deliver data permitting calculation of their cost-effectiveness in different health care reimbursement systems, by revealing the extent to which they can reduce complications and consequently the need for intensive care and the overall length of hospital stay. After discharge, key cost drivers are related to chronic cardiopulmonary diseases (other than PE itself) leading to frequent readmissions, persistent symptoms, and functional limitations which result in poor quality of life, productivity loss, and substantial indirect costs. Implementation of structured outpatient programmes with a holistic approach to post-PE care, targeting overall cardiovascular health and the patient's well-being, bears the potential to cost-effectively reduce the overall socioeconomic burden of PE.

Do low-risk patients really need follow-up after a pulmonary embolism?

BACKGROUND

The British Thoracic Society recommend that pulmonary embolism (PE) patients with low-risk Pulmonary Embolism Severity Index (PESI) scores are considered for outpatient (OP) management, in settings where robust pathways for follow-up and monitoring exist.

METHODS

Retrospective cohort study. We reviewed the electronic records of 109 consecutive PE patients considered appropriate for OP management. Primary outcomes were the incidence of recurrent venous thromboembolism, major bleeding, mortality at 1 year and evidence of chronic thromboembolic pulmonary hypertension (CTEPH).

RESULTS

Low-risk PESI scores (I-II) were recorded in 78 (72%) patients, with higher scores a consequence of age and comorbidity rather than haemodynamic instability. There was a low rate of adverse outcomes despite a lack of formal follow up for most patients. There was no evidence of CTEPH in 34 patients who underwent echocardiography.

CONCLUSION

Our analysis challenges the need for robust follow-up pathways for all patients with pulmonary embolism.

Catheter-directed interventions in acute pulmonary embolism. Position statement of SEC-Interventional Cardiology Association/SEC-Ischemic Heart Disease and Acute Cardiovascular Care Association/SEC-Working Group on Pulmonary Hypertension

Pulmonary embolism (PE) is the leading cause of hospital death and the third most frequent cause of cardiovascular mortality. Traditionally, treatment options have included anticoagulation, thrombolysis, or surgery; however, catheter-directed interventions (CDI), including catheter-directed thrombolysis and aspiration thrombectomy, have been developed for patients with intermediate- or high-risk PE. These techniques can rapidly improve right ventricular function, hemodynamic status, and mortality in some patients, although there is a lack of evidence from randomized controlled trials. This document, prepared by the Interventional Cardiology Association, the Association of Ischemic Heart Disease and Acute Cardiovascular Care, and the Working Group on Pulmonary Hypertension of the Spanish Society of Cardiology (SEC), reviews the current recommendations and available evidence on the management of PE. It emphasizes the importance of rapid response teams, risk stratification, and early patient monitoring in identifying candidates for reperfusion. Based on existing clinical evidence on CDI, the document discusses various clinical scenarios and provides guidance on patient selection, particularly in situations of uncertainty due to insufficient evidence. Lastly, it describes periprocedural support, highlighting the necessary multidisciplinary approach to improve outcomes and reduce morbidity and mortality in patients with PE.

The Five Pillars of Acute Right Ventricular Heart Failure Therapy: Can We Keep the Pediment in Balance?

Acute right ventricular heart failure (aRHF), a long-neglected aspect of heart disease, has recently gained attention due to an improved understanding of its pathophysiology and the development of tailored therapeutic strategies. The therapeutic approach is now built on several pillars that aim to support the stable clinical condition of the patient, starting with the central pillar of etiological or specific therapy and extending to various aspects related to hemodynamic support, ventilation support, fluid optimization, and, when necessary, advanced resources such as right ventricular assist devices (e.g., extracorporeal membrane oxygenation-ECMO, Impella RP, or ProtekDuo). This five-pillar approach summarizes the different facets of contemporary treatment for aRHF, although some aspects related to their use are still being clarified.

Combined endovascular interventions for pulmonary embolism at high altitude in Tibet

Background

Managing pulmonary embolism (PE) at extremely high altitudes poses unique challenges due to harsh environmental conditions and limited healthcare resources.

Method

This study retrospectively analyzed Tibetan PE patients in the Tibet Autonomous Region of China to evaluate the effectiveness and safety of combined endovascular interventional therapy in high-altitude areas.

Results

The average altitude of long-term residence for Tibetan patients was 3,863.4 ± 317.4 m, with an average age of 62.0 ± 16.0 years, and the time from computed tomography pulmonary angiography (CTPA) diagnosis to interventional treatment averaged 2.8 ± 2.2 days. The operation time for these patients was 106.1 ± 22.2 min, and the intraoperative dose of alteplase used was 23.3 ± 5.0 mg. All 9 patients reported profound remission of dyspnea and chest pain after endovascular interventions. The heart rate (p < 0.05) and respiratory rate (p < 0.001) of all enrolled patients were significantly decreased, and the peripheral capillary oxygen saturation (SpO2) was significantly increased (p < 0.05) after interventions. No severe complications, such as bleeding, occurred in any patient.

Conclusion

This study demonstrated the potential clinical benefits and feasibility of combined endovascular interventional therapy for treating acute PE in extreme high-altitude regions.

Effect of Filtered Blood Return on Outcomes of Pulmonary Aspiration Thrombectomy

OBJECTIVES

To assess the effects of filtered blood reinfusion (FBR) on procedural outcomes of aspiration thrombectomy for pulmonary embolism (PE).

MATERIALS AND METHODS

A total of 171 patients who underwent aspiration thrombectomy for intermediate-high-risk or high-risk PE between December 2018 and September 2022 were included, 84 of whom underwent thrombectomy with FBR and 87 without. Demographic data, vital signs, laboratory values, procedural details, pulmonary arterial pressures, transfusion needs, length of hospital stay, and procedure-related adverse events were recorded.

RESULTS

The groups did not differ at baseline, other than the FBR cohort having a higher percentage of women. There was no significant difference in postprocedural vital signs or pulmonary arterial pressure. Mean fluoroscopy time and volume of contrast medium used were lower in the FBR cohort. The drop in hemoglobin level was lower in the FBR group at both 12 (FBR, -1.065; No FBR, -1.742; P > .001) and 24 hours (FBR, -1.526; No FBR, -2.380; P > .001) after procedure; accordingly, fewer patients required transfusions in the FBR cohort (FBR, 8 (9.5%); No FBR, 20 (23.0%); P = .016). There was no difference in the number or severity of adverse events or duration of intensive care unit or hospital admission.

CONCLUSIONS

FBR use during aspiration pulmonary thrombectomy reduced blood loss and transfusion requirements but had no significant effect on procedural success or adverse event rates.

Pulmonary Embolism Post-Femoral Neck Fracture Surgery: A Critical Predictor of Five-Year Mortality

Objectives

This study examines the impact of pulmonary embolism (PE) on mortality among patients with femoral neck fractures, exploring the predictive value of preoperative PE for postoperative occurrences and associated mortality over a 5-year follow-up period.

Methods

We analyzed 2256 patients over 60 years old admitted with femoral neck fractures, focusing on those who developed DVT or PE postoperatively. Surgical intervention aimed within 48 hours without pharmacological thromboprophylaxis, utilizing mechanical prophylaxis instead. Postoperative management included Enoxaparin administration. Data analysis employed SPSS 21, with chi-squared tests, T-tests, and multivariate logistic regression to explore mortality and PE incidence.

Results

PE was diagnosed in 1.4% of patients, with a notable mortality contrast between patients with PE (87%) and those without (59.7%) over 5 years. A history of preoperative PE emerged as a significant risk factor for postoperative PE. Despite surgical variations, no significant correlation was found between surgery type and PE incidence. Early postoperative weight-bearing and institutional rehabilitation did not significantly alter PE incidence rates.

Conclusions

The study underscores the significant mortality risk associated with preoperative PE in femoral neck fracture patients. It highlights the necessity for vigilant PE risk assessment and management, challenging assumptions about the protective role of early mobility and rehabilitation in PE incidence. Further research is essential to refine patient care strategies and improve outcomes.

Targeting Fibrinolytic Inhibition for Venous Thromboembolism Treatment: Overview of an Emerging Therapeutic Approach

Venous thrombosis and pulmonary embolism (venous thromboembolism) are important causes of morbidity and mortality worldwide. In patients with venous thromboembolism, thrombi obstruct blood vessels and resist physiological dissolution (fibrinolysis), which can be life threatening and cause chronic complications. Plasminogen activator therapy, which was developed >50 years ago, is effective in dissolving thrombi but has unacceptable bleeding risks. Safe dissolution of thrombi in patients with venous thromboembolism has been elusive despite multiple innovations in plasminogen activator design and catheter-based therapy. Evidence now suggests that fibrinolysis is rigidly controlled by endogenous fibrinolysis inhibitors, including α2-antiplasmin, plasminogen activator inhibitor-1, and thrombin-activable fibrinolysis inhibitor. Elevated levels of these fibrinolysis inhibitors are associated with an increased risk of venous thromboembolism in humans. New therapeutic paradigms suggest that accelerated and effective fibrinolysis may be achieved safely by therapeutically targeting these fibrinolytic inhibitors in venous thromboembolism. In this article, we discuss the role of fibrinolytic components in venous thromboembolism and the current status of research and development targeting fibrinolysis inhibitors.

Advancing the management of acute intermediate-high-risk pulmonary embolism: The enduring legacy of Professor Guy Meyer

Only few years after the first report on diagnosing acute pulmonary embolism (PE) with pulmonary angiography, studies began to investigate the effectiveness and safety of thrombolytic therapy for achieving early reperfusion. In 1992, Guy Meyer demonstrated the fast improvement of pulmonary haemodynamics after alteplase administration; this drug has remained the mainstay of thrombolysis for PE over almost 35 years. In the meantime, algorithms for PE risk stratification continued to evolve. The landmark Pulmonary Embolism International Thrombolysis (PEITHO) trial, led by Guy Meyer, demonstrated the clinical efficacy of thrombolysis for intermediate-risk PE, albeit at a relatively high risk of major, particularly intracranial bleeding. Today, systemic thrombolysis plays an only minor role in the real-world treatment of acute PE in the United States and Europe, but major trials are underway to test safer reperfusion regimens. Of those, the PEITHO-3 study, conceived by Guy Meyer and other European and North American experts, is an ongoing randomised, placebo-controlled, double-blind, multinational academic trial. The primary objective is to assess the efficacy of reduced-dose intravenous thrombolytic therapy against the background of heparin anticoagulation in patients with intermediate-high-risk PE. In parallel, trials with similar design are testing the efficacy and safety of catheter-directed local thrombolysis or mechanical thrombectomy. Increasingly, focus is being placed on long-term functional and patient-reported outcomes, including quality of life indicators, as well as on the utilization of health care resources. The pioneering work of Guy Meyer will thus continue to have a major impact on the management of PE for years to come.

Clinical, Functional, and Quality-of-Life Outcomes after Computer Assisted Vacuum Thrombectomy for Pulmonary Embolism: Interim Analysis of the STRIKE-PE Study

PURPOSE

To report the first interim analysis of the STRIKE-PE study, evaluating the safety and effectiveness of computer assisted vaccum thrombectomy (CAVT) for the treatment of acute pulmonary embolism (PE).

MATERIALS AND METHODS

This prospective, international, multicenter study will enroll 600 adult patients with acute PE of ≤14 days and a right ventricle (RV)-to-left ventricle (LV) ratio of ≥0.9 who receive first-line endovascular treatment with CAVT using the Indigo Aspiration System (Penumbra, Alameda, California). Primary endpoints are change in RV/LV ratio and incidence of composite major adverse events (MAEs) within 48 hours. Secondary endpoints include functional and quality-of-life (QoL) assessments.

RESULTS

The first 150 consecutive patients were treated with 12F catheter CAVT. Mean age was 61.3 years, 54.7% were men, 94.7% presented with intermediate-risk PE, and 5.3% presented with high-risk PE. Median thrombectomy and procedure times were 33.5 minutes and 70.0 minutes, respectively, resulting in a mean reduction in systolic pulmonary artery pressure of 16.3% (P < .001). Mean RV/LV ratio decreased from 1.39 to 1.01 at 48 hours, a 25.7% reduction (P < .001). Four (2.7%) patients experienced a composite MAE within 48 hours. At 90-day follow-up, patients exhibited statistically significant improvements in the Borg dyspnea scale score and QoL measures, and the New York Heart Association class distribution returned to that reported before the index PE.

CONCLUSIONS

Interim results from the STRIKE-PE study demonstrate a significant reduction in pulmonary artery pressure and RV/LV ratio, a median thrombectomy time of 33.5 minutes, a composite MAE rate of 2.7%, and significant improvements in 90-day functional and QoL outcomes.

Adverse Event Profiles of the Third-Generation Aromatase Inhibitors: Analysis of Spontaneous Reports Submitted to FAERS

The third-generation aromatase inhibitors (AIs), represented by letrozole, anastrozole, and exemestane, have been used as a standard first-line adjuvant therapy for postmenopausal breast cancer patients with positive hormone receptor. However, their safety in the real world has not been systematically analyzed. We used the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) to investigate adverse event (AE) profiles of the three AIs, covering the period from Q1 2004 to Q3 2023. The time-to-event onset profiles and cumulative incidence were analyzed by Weibull shape parameter test and Kaplan-Meier method, respectively. The disproportionality analysis was utilized to assess drug toxicity risk. Based on the FAERS database, 18,035, 8242, and 7011 reports listing letrozole, anastrozole, and exemestane as primary suspected drugs were extracted, respectively. AEs associated with anastrozole displayed the latest onset (p < 0.0001); meanwhile, WSP test showed that all three AIs had early failure-type profiles. At the preferred term level, we acquired 95, 59, and 42 significant signals associated with letrozole, anastrozole, and exemestane, which involved 18, 13, and 15 system organ classes, respectively. The three AIs all reported that their strongest AE signal was trigger finger. Neutropenia was the most frequent AE for letrozole, while the highest occurrences of anastrozole and exemestane were arthralgia. We also found that interstitial lung disease, a rare but serious AE, showed strong signal intensity in all three AIs. Additionally, letrozole was also associated with lots of other rare but serious AEs in hematologic, respiratory, and hepatic systems, which were not recorded in the instructions. Our analysis of safety warning signals of the third-generation AIs from the FAERS database provided reference for clinical safe and rational drug use.

Mechanical Thrombectomy Complicated by Pulmonary Artery Pseudoaneurysm Treated With Endovascular Thrombin Injection

Pulmonary thrombectomy for acute pulmonary arterial embolism has emerged as an effective endovascular therapy for high-risk patients. While the procedure is typically performed safely and efficaciously, given the nature of the treatment, complications may rarely occur. Pulmonary pseudoaneurysm is a rare condition occurring in a variety of settings, including pulmonary thrombectomy. To our knowledge, we present the first published case of pulmonary artery pseudoaneurysm following percutaneous thrombectomy, along with its successful endovascular management.

Use of Extracorporeal Membrane Oxygenation-Facilitated Large-Bore Catheter Embolectomy in the Treatment of Acute Pulmonary Embolism Complicated by Shock

This article reports the case of a 42-year-old man who presented with a saddle pulmonary embolus complicated by normotensive cardiogenic shock. The patient was first stabilized with venoarterial extracorporeal membrane oxygenation. Then, while the patient was still on extracorporeal membrane oxygenation, thrombectomy with a large-bore catheter device was performed that resulted in a large decrease in pulmonary artery pressures and a clinically significant increase in cardiac index, with rapid clinical improvement. Complete recovery of the patient's cardiopulmonary status has been maintained at intermediate-term follow-up. This treatment strategy should be considered favorably in the treatment of patients presenting with pulmonary embolism complicated by cardiogenic shock.

Modelling costs of interventional pulmonary embolism treatment: implications of US trends for a European healthcare system

AIMS

Catheter-directed treatment (CDT) of acute pulmonary embolism (PE) is entering a growth phase in Europe following a steady increase in the USA in the past decade, but the potential economic impact on European healthcare systems remains unknown.

METHODS AND RESULTS

We built two statistical models for the monthly trend of proportion of CDT among patients with severe (intermediate- or high-risk) PE in the USA. The conservative model was based on admission data from the National Inpatient Sample (NIS) 2016-20 and the model reflecting increasing access to advanced treatment from the PERT™ national quality assurance database registry 2018-21. By applying these models to the forecast of annual PE-related hospitalizations in Germany, we calculated the annual number of severe PE cases and the expected increase in CDT use for the period 2025-30. The NIS-based model yielded a slow increase, reaching 3.1% (95% confidence interval 3.0-3.2%) among all hospitalizations with PE in 2030; in the PERT-based model, increase would be steeper, reaching 8.7% (8.3-9.2%). Based on current reimbursement rates, we estimated an increase of annual costs for PE-related hospitalizations in Germany ranging from 15.3 to 49.8 million euros by 2030. This calculation does not account for potential cost savings, including those from reduced length of hospital stay.

CONCLUSION

Our approach and results, which may be adapted to other European healthcare systems, provide a benchmark for healthcare costs expected to result from CDT. Data from ongoing trials on clinical benefits and cost savings are needed to determine cost-effectiveness and inform reimbursement decisions.

Catheter Interventions for Pulmonary Embolism: Mechanical Thrombectomy Versus Thrombolytics

Pulmonary embolism is a debilitating and potentially life-threatening disease characterized by high mortality and long-term adverse outcomes. Traditional treatment options are fraught with serious bleeding risks and incomplete thrombus removal, necessitating the development of innovative treatment strategies. While new interventional approaches offer promising potential for improved outcomes with fewer serious complications, their rapid development and need for more comparative clinical evidence makes it challenging for physicians to select the optimal treatment for each patient among the many options. This review summarizes the current published clinical data for both traditional treatments and more recent interventional approaches indicated for pulmonary embolism. While published studies thus far suggest that these newer interventional devices offer safe and effective options, more data is needed to understand their impact relative to the standard of care. The studies in progress that are anticipated to provide needed evidence are reviewed here since they will be critical for helping physicians make informed treatment choices and potentially driving necessary guideline changes.

Management of high-risk pulmonary embolism in the emergency department: A narrative review

BACKGROUND

High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE.

OBJECTIVE

This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations.

DISCUSSION

High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions.

CONCLUSIONS

Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.

Electrocardiographic Changes after Endovascular Mechanical Thrombectomy in a Patient with Pulmonary Embolism-A Case Report and Literature Review

Background: Pulmonary embolism (PE) is a common disease with an annual incidence of about 1/1000 persons. About every sixth patient dies within the first 30 days after diagnosis. The electrocardiogram (ECG) is one of the first diagnostic tests performed, and is able to confirm the suspicion of PE with typical electrocardiographic signs. Some ECG signs and their regression are also prognostically relevant. Endovascular mechanical thrombectomy is one option for PE treatment, and aims to relieve right heart strain immediately. The first studies on endovascular mechanical thrombectomy using a dedicated device (FlowTriever System, Inari Medical, Irvine, CA, USA) yielded promising results. Methods: In the following, we report the case of a 66-year-old male patient who presented with New York Heart Association III dyspnea in our emergency department. Among typical clinical and laboratory results, he displayed very impressive electrocardiographic and radiological findings at the time of PE diagnosis. Results: After endovascular mechanical thrombectomy, the patient's complaints and pulmonary hemodynamics improved remarkably. In contrast, the ECG worsened paradoxically 18 h after intervention. Nevertheless, control echocardiography 4 days after the intervention no longer showed any signs of right heart strain, and dyspnea had disappeared completely. At a 4-month follow-up visit, the patient presented as completely symptom-free with a high quality of life. His ECG and echocardiography were normal and excluded recurrent right heart strain. Conclusions: Overall, the patient benefitted remarkably from endovascular mechanical thrombectomy, resulting in an almost complete resolution of electrocardiographic PE signs at the 4-month follow-up after exhibiting multiple typical electrocardiographic PE signs at time of diagnosis and initial electrocardiographic worsening 18 h post successful intervention.

Integrating Pharmacomechanical Treatments for Pulmonary Embolism Management within a Hub-and-Spoke System in the Swiss Ticino Region

The Swiss Ticino regional pulmonary embolism response team (PERT) features direct access to various pharmacomechanical PE management options within a hub/spoke system, by integrating evidence, guidelines' recommendations and personal experiences. This system involves a collaborative management of patients among the hospitals distributed throughout the region, which refer selected intermediate-high or high PE patients to a second-level hub center, located in Lugano at Cardiocentro Ticino, belonging to the Ente Ospedaliero Cantonale (EOC). The hub provides 24/7 catheterization laboratory activation for catheter-based intervention (CBI), surgical embolectomy and/or a mechanical support system such as extracorporeal membrane oxygenation (ECMO). The hub hosts PE patients after percutaneous or surgical intervention in two intensive care units, one specialized in cardiovascular anesthesiology, to be preferred for patients without relevant comorbidities or with hemodynamic instability and one specialized in post-surgical care, to be preferred for PE patients after trauma or surgery or with relevant comorbidities, such as cancer. From April 2022 to December 2023, a total of 65 patients were referred to the hub for CBI, including ultrasound-assisted catheter-directed thrombolysis (USAT) or large-bore aspiration intervention. No patient received ECMO or underwent surgical embolectomy.

Pulmonary Embolism: An Update Based on the Revised AWMF-S2k Guideline

Pulmonary embolism (PE) is the third most common acute cardiovascular disease. The risk of PE increases with age and mortality is high. Patients are stratified into hemodynamically stable versus unstable patients, as this has important implications for diagnosis and therapy. Since clinical signs and symptoms of acute PE are nonspecific, the clinical likelihood of PE is estimated to guide diagnostic pathways. D-dimer testing is performed in hemodynamically stable patients with low or intermediate probability of PE and the visualization of thromboembolism and its sequelae is commonly achieved with computed tomography pulmonary angiography (CTPA), supplemented by ultrasound techniques. With confirmed PE, another risk stratification estimates disease severity and defines intensity and setting of the ensuing treatment. The therapeutic spectrum ranges from outpatient treatment with initial oral anticoagulation to thrombolytic or interventional treatment in the intensive care unit or catheterization laboratory. In single cases, even acute surgical thrombectomy is attempted.

Ultrasound-assisted endovascular thrombolysis versus large-bore thrombectomy in acute intermediate-high risk pulmonary embolism: The propensity-matched EKNARI cohort study

BACKGROUND

Ultrasound-assisted thrombolysis (USAT) and large-bore-thrombectomy (LBT) are under investigation for the treatment of intermediate-high and high-risk pulmonary embolisms (PE). Comparative studies investigating both devices are scarce.

AIMS

This study aimed to compare the safety and efficacy of the two most frequently used devices for treatment of acute PE.

METHODS

This multicenter, retrospective study included 125 patients undergoing LBT or USAT for intermediate- or high-risk PE between 2019 and 2023. Nearest neighbor propensity matching with logistic regression was used to achieve balance on potential confounders. The primary outcome was the change in the right to left ventricular (RV/LV) ratio between baseline and 24 h.

RESULTS

A total of 125 patients were included. After propensity score matching, 95 patients remained in the sample, of which 69 (73%) underwent USAT and 26 (27%) LBT. The RV/LV ratio decrease between baseline and 24 h was greater in the LBT than in the USAT group (adjusted between-group difference: -0.10, 95% CI: -0.16 to -0.04; p = 0.001). Both procedures were safe and adverse events occurred rarely (10% following USAT vs. 4% following LBT; p = 0.439).

CONCLUSION

In acute intermediate-high and high-risk PE, both LBT and USAT were feasible and safe. The reduction in RV/LV ratio was greater following LBT than USAT. Further randomized controlled trials are needed to confirm these findings.

Pulmonary embolism with paradoxical embolization to right coronary artery in the presence of a large patent foramen ovale: a case report

Background

Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging.

Case summary

A 64-year-old man presented to hospital with acute chest pain, shortness of breath, and pulmonary oedema. Electrocardiogram revealed ST-elevation myocardial infarction. D-dimer was 18.8 mg/L fibrinogen equivalent units (FEU) (normal <0.64), and troponin was 25 (normal 5-14 ng/L). After systemic thrombolysis, respiratory failure persisted, and the arterial blood gas showed PaO2 of 6.0 kPa (normal 10.5-13.5 kPa), with 100% oxygen delivery via high-flow nasal cannula. A computed tomography diagnosed bilateral lobar PE, and coronary angiogram showed multiple thrombus in the right coronary artery. A bubble study with thoracic echocardiogram revealed a large right-left inter-atrial shunt. The patient denied treatment with extracorporeal membrane oxygenation and surgical thrombectomy. With no access to percutaneous catheter-directed thrombectomy, the patient received three separate thrombolysis treatments followed by a continued infusion for 22 h. After 6 weeks in hospital, the patient was discharged to rehab.

Discussion

For a long time, PE has been largely seen as a medical disease. Intra-cardiac shunts such as patent foramen ovale can complicate thrombo-venous disease and introduce paradoxical shunts leading to arterial emboli and persistent hypoxaemia. Over recent years, modern percutaneous catheter-directed thrombectomy has been developed for both high-risk and intermediate to high-risk PEs. Thrombectomy might improve right ventricular function and haemodynamics, but there is lacking evidence from randomized trials on efficacy, safety, and long-term outcome.

Effectiveness and Safety of Large-Bore Aspiration Thrombectomy for Intermediate- or High-Risk Pulmonary Embolism

PURPOSE

To evaluate effectiveness and safety of large-bore mechanical thrombectomy of intermediate- or high-risk pulmonary embolism (PE) and factors associated with effectiveness.

MATERIALS AND METHODS

A retrospective review of 257 patients with intermediate- or high-risk PE who underwent mechanical thrombectomy using the Flowtriever system (Inari Medical, Irvine, California) between July 2019 and November 2021 was conducted. Data were analyzed using the linear regression and Kaplan-Meier methods with a Type 1 error set at 0.05.

RESULTS

Patients' mean age was 62 years, and 51% were male. PE risk was classified as high, intermediate-high, and intermediate-low in 37 (14%), 201 (78%), and 18 (7%) of the patients, respectively. Procedural technical success was 100%. The mean pulmonary artery pressure (MPAP) decreased from a mean of 32 mmHg (SD ± 9) before to 24 mmHg (SD ± 9) after thrombectomy (mean decrease, 8 mmHg [SD ± 6]; P < .0001). Immediate complications occurred in 2% of the patients. Postprocedural 30-day and all-time PE-attributable mortality in a mean of 1.3-year follow-up was 2% and 6%, respectively. In multivariate analysis, the presence of lower extremity DVT at presentation (β ± SE, -7.60 ± 3.22; P = .019) and a higher prethrombectomy MPAP (β ± SE, -0.19 ± 0.04; P < .001) were associated with lower degrees of decrease in MPAP in the intermediate-high-risk PE group. Among 14 patients with postthrombectomy PE-attributable mortality, 13 had postthrombectomy MPAPs of >20 mmHg.

CONCLUSIONS

Large-bore aspiration thrombectomy is a safe and effective treatment for reducing PAP in patients with intermediate- or high-risk PE. Postthrombectomy MPAPs of >20 mmHg might indicate postthrombectomy PE-attributable mortality in high-risk patients.

Management of high and intermediate-high risk pulmonary embolism: A position paper of the Interventional Cardiology Working Group of the Italian Society of Cardiology

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.

In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices

BACKGROUND

A significant proportion of pulmonary embolisms (PEs) occurs in patients during hospitalisation for another reason. However, limited data regarding differences between out-of-hospital PE (OHPE) and in-hospital PE (IHPE) is available. We aimed to compare these groups regarding their clinical characteristics, biochemical markers, and echocardiographic indices.

METHODS

This was a prospective, single-arm, single-centre study. Adult consecutive patients with non-COVID-related PE from September 2019 to March 2022 were included and followed up for 12 months.

RESULTS

The study included 180 (84 women) patients, with 89 (49.4%) suffering from IHPE. IHPE patients were older, they more often had cancer, were diagnosed earlier after the onset of symptoms, they had less frequent pain and higher values of high sensitivity troponin I and brain natriuretic peptide levels compared to OHPE patients. Echocardiographic right ventricular (RV) dysfunction was detected in similar proportions in the 2 groups. IHPE had increased in-hospital mortality (14.6% vs. 3.3%, p = 0.008) and similar post-discharge to 12-month mortality with OHPE patients.

CONCLUSIONS

In this prospective cohort study, IHPE differed from OHPE patients regarding age, comorbidities, symptoms, and levels of biomarkers associated with RV dysfunction. IHPE patients had higher in-hospital mortality compared to OHPE patients and a similar risk of death after discharge.

Cutting-Edge Techniques and Drugs for the Treatment of Pulmonary Embolism: Current Knowledge and Future Perspectives

Pulmonary embolism (PE) is a potentially life-threatening condition requiring prompt diagnosis and treatment. Recent advances have led to the development of newer techniques and drugs aimed at improving PE management, reducing its associated morbidity and mortality and the complications related to anticoagulation. This review provides an overview of the current knowledge and future perspectives on PE treatment. Anticoagulation represents the first-line treatment of hemodynamically stable PE, direct oral anticoagulants being a safe and effective alternative to traditional anticoagulation: these drugs have a rapid onset of action, predictable pharmacokinetics, and low bleeding risk. Systemic fibrinolysis is suggested in patients with cardiac arrest, refractory hypotension, or shock due to PE. With this narrative review, we aim to assess the state of the art of newer techniques and drugs that could radically improve PE management in the near future: (i) mechanical thrombectomy and pulmonary embolectomy are promising techniques reserved to patients with massive PE and contraindications or failure to systemic thrombolysis; (ii) catheter-directed thrombolysis is a minimally invasive approach that can be suggested for the treatment of massive or submassive PE, but the lack of large, randomized controlled trials represents a limitation to widespread use; (iii) novel pharmacological approaches, by agents inhibiting thrombin-activatable fibrinolysis inhibitor, factor Xia, and the complement cascade, are currently under investigation to improve PE-related outcomes in specific settings.

Early predictors of clinical deterioration in intermediate-high risk pulmonary embolism: clinical needs, research imperatives, and pathways forward

A subset of intermediate-high risk pulmonary embolism (PE) patients will suffer clinical deterioration in the early hours following the acute event. Current evidence-based guidelines for the management of acute PE have provided limited direction for identification of which intermediate-high risk PE patients will go on to develop haemodynamic decompensation. Furthermore, a paucity of data further hampers guideline recommendations regarding the optimal approach and duration of intensive monitoring, best methods to assess the early response to anticoagulation, and the ideal window for reperfusion therapy, if decompensation threatens. The aim of the present article is to identify the current unmet needs related to the early identification of intermediate-high risk PE patients at higher risk of clinical deterioration and mortality during the early hours after the acute cardiovascular event and suggest some potential strategies to further explore gaps in the literature.

Superhydrophilic and Antifriction Thin Hydrogel Formed under Mild Conditions for Medical Bare Metal Guide Wires

Medical guide wires play a crucial role in the process of intravascular interventional therapy. However, it is essential for bare metal guide wires to possess both hydrophilic lubricity and coating durability, avoiding tissue damage caused by friction inside the blood vessel during the interventional procedure. Additionally, it is still a huge challenge for diverse metal materials to bind with polymer coatings easily. Herein, we present a hydrogel coating scheme and its preparation method for various wires under mild conditions for environmental protection purposes. The preparation process involves surface pretreatment, including low-temperature heating and silanization, followed by a two-step dip coating and ultraviolet polymerization. The whole process leads to the formation of an interpenetrating cross-linked hydrogel network from the substrate to the surface section. This study confirms the superhydrophilicity and lubricity of three metal wires with the designed coating, especially reducing the friction significantly by ≥ 95%. The thin coating (average thickness <6.2 μm) demonstrates strong adhesion with various substrates and exhibits resistance to 25 or even 125 cycles of friction, indicating excellent stability and preventing easy detachment. The finally prepared composite nickel-titanium (NiTi) guide wire with stainless steel (SS) and platinum-tungsten (Pt-W) coils (overall diameter of ∼0.36 mm) shows satisfactory performance with a friction of 0.183 N for 25 cycles, meeting the clinical requirements (average friction ≤0.2 N) for interventional operation. These findings highlight the potential of this study in advancing the development of medical devices, particularly in the field of intravascular interventional therapy.

Mechanical thrombectomy in intermediate- and high-risk acute pulmonary embolism: hemodynamic outcomes at three months

BACKGROUND

Mechanical thrombectomy has been shown to reduce thrombus burden and pulmonary artery pressure (PAP) and to improve right ventricular (RV) function in patients with high-risk or intermediate-high-risk pulmonary embolism (PE). As hemodynamic data after mechanical thrombectomy for PE are scarce, we aimed to assess the hemodynamic effects of mechanical thrombectomy in acute PE with right heart overload.

METHODS

In this prospective, open-label study, patients with acute symptomatic, computed tomography-documented PE with signs of right heart overload underwent mechanical thrombectomy using the FlowTriever System. Right heart catheterization was performed immediately before and after thrombectomy and after three months. Transthoracic echocardiography was performed before thrombectomy, discharge, and at three months. This analysis was done after 20 patients completed three months of follow-up.

RESULTS

Twenty-nine patients (34% female) underwent mechanical thrombectomy, of which 20 completed three months follow-up with right heart catheterization. Most patients were at high (17%) or intermediate-high (76%) risk and had bilateral PE (79%). Before thrombectomy, systolic PAP (sPAP) was severely elevated (mean 51.3 ± 11.6 mmHg). Mean sPAP dropped by -15.0 mmHg (95% confidence interval [CI]: -18.9 to -11.0; p < 0.001) immediately after the procedure and continued to decrease from post-thrombectomy to three months (-6.4 mmHg, 95% CI: -10-0 to -2.9; p = 0.002). RV/left ventricular (LV) ratio immediately reduced within two days by -0.37 (95% CI: -0.47 to -0.27; p < 0.001). The proportion of patients with a tricuspid annular plane systolic excursion (TAPSE)/sPAP ratio < 0.31 mm/mmHg decreased from 28% at baseline to 0% before discharge and at three months (p = 0.007). There were no procedure-related major adverse events.

CONCLUSIONS

Mechanical thrombectomy for acute PE was safe and immediately reduced PAP and improved right heart function. The reduction in PAP was maintained at three months follow-up.