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Christodoulou KC, Mohr K, Uphaus T, Jägersberg M, Valerio L, Farmakis IT, Münzel T, Lurz P, Konstantinides SV, Hobohm L, Keller K. Evolving patterns of intracranial hemorrhage in advanced therapies in patients with acute pulmonary embolism. Thromb Res 2024; 243:109168. [PMID: 39326193 DOI: 10.1016/j.thromres.2024.109168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 09/15/2024] [Accepted: 09/19/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Dissecting trends and contributing risk factors for intracranial hemorrhage (ICH) in patients treated for acute pulmonary embolism (PE) may allow for a better patient selection for existing and emerging treatment options. METHODS The German nationwide inpatient sample was screened for patients admitted due to PE 2005-2020. Hospitalizations were stratified for the occurrence of ICH; risk factors for ICH and temporal trends were investigated. RESULTS Overall, 816,653 hospitalizations due to acute PE in the period 2005-2020 were analyzed in the study. ICH was reported in 2516 (0.3 %) hospitalizations, and time trend analysis revealed a fluctuating but overall, largely unchanged annual incidence. There was an increase of ICH with age. Patients with ICH had a higher comorbidity burden (Charlson-Comorbidity-Index [CCI], 5.0 [4.0-7.0] vs. 4.0 [2.0-5.0]; P < 0.001), and higher CCI was associated with an OR of 1.26 (95%CI 1.24-1.27) for ICH. Further independent risk factors for ICH were age ≥ 70 years (OR 1.23 [1.12-1.34]), severe (versus low-risk) PE (OR 3.09 [2.84-3.35]), surgery (OR 1.59 [1.47-1.72]), acute kidney injury (OR 3.60 [3.09-4.18]), and ischemic stroke (OR 14.64 [12.61-17.00]). The identified risk factors for ICH varied among different reperfusion treatment groups. As expected, ICH had a substantial impact on case-fatality of PE (OR 6.16 [5.64-6.72]; P < 0.001). CONCLUSIONS Incidence of ICH in patients hospitalized for acute PE in Germany was overall low and depended on the patients' comorbidity burden. Identifying patients at risk for ICH allows tailored patient selection for the different reperfusion treatments and might prevent ICH.
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Affiliation(s)
- Konstantinos C Christodoulou
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Katharina Mohr
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Timo Uphaus
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Max Jägersberg
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Philipp Lurz
- Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Department of Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
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2
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Zuin M, Bikdeli B, Ballard-Hernandez J, Barco S, Battinelli EM, Giannakoulas G, Jimenez D, Klok FA, Krishnathasan D, Lang IM, Moores L, Sylvester KW, Weitz JI, Piazza G. International Clinical Practice Guideline Recommendations for Acute Pulmonary Embolism: Harmony, Dissonance, and Silence. J Am Coll Cardiol 2024; 84:1561-1577. [PMID: 39384264 DOI: 10.1016/j.jacc.2024.07.044] [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: 03/08/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 10/11/2024]
Abstract
Despite abundant clinical innovation and burgeoning scientific investigation, pulmonary embolism (PE) has continued to pose a diagnostic and management challenge worldwide. Aging populations, patients living with a mounting number of chronic medical conditions, particularly cancer, and increasingly prevalent health care disparities herald a growing burden of PE. In the meantime, navigating expanding strategies for immediate and long-term anticoagulation, as well as advanced therapies, including catheter-based interventions for patients with more severe PE, has become progressively daunting. Accordingly, clinicians frequently turn to evidence-based clinical practice guidelines for diagnostic and management recommendations. However, numerous international guidelines, heterogeneity in recommendations, as well as areas of uncertainty or omission may leave the readers and clinicians without a clear management pathway. In this review of international PE guidelines, we highlight key areas of consistency, difference, and lack of recommendations (silence) with an emphasis on critical clinical and research needs.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy.
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
| | - Jennifer Ballard-Hernandez
- Cardiology Division, Department of Medicine, Department of Veterans Affairs, VA Long Beach Healthcare System, Long Beach, California, USA; Sue and Bill Gross School of Nursing University of California-Irvine, Irvine, California, USA
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Elisabeth M Battinelli
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, LUMC, Leiden, the Netherlands
| | - Darsiya Krishnathasan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Lisa Moores
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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3
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Dastani M, Askari VR, Nasimi Shad A, Ghorbani N, Baradaran Rahimi V. Investigating the effects of systemic thrombolysis on electrocardiography and pulmonary artery blood pressure in patients with pulmonary embolism. Health Sci Rep 2024; 7:e70085. [PMID: 39355097 PMCID: PMC11443320 DOI: 10.1002/hsr2.70085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 07/30/2024] [Accepted: 09/05/2024] [Indexed: 10/03/2024] Open
Abstract
Background and Aims We aimed to evaluate the association between electrocardiography (ECG) and echocardiographic findings in patients with pulmonary embolism (PE) before and after systemic thrombolysis. Methods We included 38 PE patients admitted to the hospital with approved right ventricular (RV) dysfunction who were indicated for systemic thrombolysis. Indications for systemic thrombolysis were considered as patients who were either hemodynamically unstable on admission or became unstable in the course of hospital admission. Systemic thrombolysis was performed by either Reteplase or Alteplase. ECG and echocardiographic findings were documented at baseline and 12-24 h following systemic thrombolysis. Results Our results showed that TAPSE significantly increased while RV size and pulmonary artery systolic pressure (PAP) notably decreased after systemic thrombolysis (p < 0.001). The ECG abnormalities markedly diminished after systemic thrombolysis in PE patients (p < 0.001). Additionally, 100% of our patients had more than one ECG abnormality at baseline, while 55.3% had no ECG abnormalities after systemic thrombolysis. Further, the median number of ECG abnormalities remarkably attenuated after systemic thrombolysis (from 2.0 (1.0) to 0.0 (1.0), p < 0.001). Our results also revealed that delta RV size (r = 0.51, p = 0.001) and delta TAPSE (r = 0.4, p = 0.012) were positively correlated while mortality (r = -0.55, p = 0.001) was negatively associated with changes in the number of ECG abnormalities before and after systemic thrombolysis. Conclusion We showed that systemic thrombolysis improved echocardiographic and electrocardiographic findings in PE patients. Additionally, a greater decreased number of ECG abnormalities after systemic thrombolysis was accompanied by more improvement in RV size and TAPSE and a lower mortality rate.
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Affiliation(s)
- Mostafa Dastani
- Department of Cardiovascular DiseasesFaculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Vahid Reza Askari
- Pharmacological Research Center of Medicinal PlantsMashhad University of Medical SciencesMashhadIran
| | - Arya Nasimi Shad
- Student Research Committee, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Niyayesh Ghorbani
- Department of Cardiovascular DiseasesFaculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Vafa Baradaran Rahimi
- Department of Cardiovascular DiseasesFaculty of MedicineMashhad University of Medical SciencesMashhadIran
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4
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Bali AD, Sharma T, Villela MA, Naidu SS, Goldberg J. Interventional Therapies and Mechanical Circulatory Support for Acute Pulmonary Embolism. J Card Fail 2024; 30:1319-1329. [PMID: 39389743 DOI: 10.1016/j.cardfail.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/03/2024] [Accepted: 07/30/2024] [Indexed: 10/12/2024]
Abstract
Acute pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality, with most PE-related mortality associated with acute right ventricular (RV) failure. Despite an increase in attention to acute PE with new endovascular devices for therapy and the adoption of multidisciplinary clinical treatment teams, mortality rates remain high in patients who present with PE-related hemodynamic compromise. Currently, the advanced treatment modalities for acute high-risk and intermediate high-risk PE are limited to several interventional modalities-open surgical embolectomy and systemic fibrinolytic agents. The purpose of this state-of-the-art review is to describe modern therapeutic techniques and strategies (both interventional and surgical) and the role of mechanical circulatory support (MCS) for hemodynamic compromise in PE.
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Affiliation(s)
- Atul D Bali
- Department of Cardiology, Lenox Hill Hospital, New York, NY.
| | - Tanya Sharma
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
| | | | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
| | - Joshua Goldberg
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY
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5
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Tébar-Márquez D, Jurado-Román A, Jiménez-Valero S, Galeote G, García-Muñoz A, Lorenzo-Hernández A, Fernández-Capitán C, Torres Santos-Olmo R, Alcolea-Batres S, Ugueto C, Vera-Vera S, Moreno R. Percutaneous Thrombectomy With Flowtriever System in Pregnant Women With High-Risk Pulmonary Embolism and Contraindications to Systemic Thrombolysis. J Endovasc Ther 2024:15266028241280508. [PMID: 39257020 DOI: 10.1177/15266028241280508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
CLINICAL IMPACT Through these clinical cases, we present a new protocol of action, updated with the latest evidence on percutaneous pulmonary thrombectomy using dedicated catheters, for high-risk PE in pregnant women or during the early postpartum period.
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Affiliation(s)
| | | | | | | | - Andoni García-Muñoz
- Intensive Care Medicine Department, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | - Clara Ugueto
- Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Silvio Vera-Vera
- Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Raúl Moreno
- Cardiology Department, La Paz University Hospital, Madrid, Spain
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6
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Konstantinides SV, Sanchez O, Goldhaber SZ, Meneveau N. Advancing the management of acute intermediate-high-risk pulmonary embolism: The enduring legacy of Professor Guy Meyer. Presse Med 2024; 53:104248. [PMID: 39244019 DOI: 10.1016/j.lpm.2024.104248] [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: 07/07/2024] [Accepted: 09/03/2024] [Indexed: 09/09/2024] Open
Abstract
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.
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Affiliation(s)
- 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, Greece.
| | - Olivier Sanchez
- Université Paris Cité; Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP; INSERM UMRS 1140, Paris, France; FCRIN INNOVTE, St-Etienne, France
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicolas Meneveau
- SINERGIES, University of Franche-Comté, Besançon, France; Department of Cardiology, University Hospital Besançon, Besançon, France
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7
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Jandhyala A, Elahi J, Ganti L, Sherin KM. Post-operative Saddle Pulmonary Embolism: A Case Report. Cureus 2024; 16:e69175. [PMID: 39398753 PMCID: PMC11468588 DOI: 10.7759/cureus.69175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 09/10/2024] [Indexed: 10/15/2024] Open
Abstract
Pulmonary embolisms are serious complications that can arise from surgical procedures involving the extremities due to the risk of deep vein thrombosis (DVT) and subsequent embolism. This life-threatening condition occurs when an embolus lodges at the bifurcation of the main pulmonary arteries, compromising blood flow to the lungs. Treatment options for pulmonary embolism primarily include anticoagulation therapy, thrombolysis, thrombectomy, and inferior vena cava (IVC) filter placement. Given that cases of saddle pulmonary embolism are rare but potentially fatal, healthcare providers must maintain a high index of suspicion and implement rigorous preventive measures to mitigate the risk in surgical patients.
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Affiliation(s)
| | - Jasra Elahi
- Biotechnology, Rutgers University, New Jersey, USA
| | - Latha Ganti
- Emergency Medicine and Neurology, University of Central Florida, Orlando, USA
- Research, Orlando College of Osteopathic Medicine, Winter Garden, USA
- Medical Science, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Kevin M Sherin
- Primary Care, Orlando College of Osteopathic Medicine, Orlando, USA
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8
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Henkin S, Ujueta F, Sato A, Piazza G. Acute Pulmonary Embolism: Evidence, Innovation, and Horizons. Curr Cardiol Rep 2024:10.1007/s11886-024-02128-0. [PMID: 39215952 DOI: 10.1007/s11886-024-02128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE OF REVIEW Pulmonary embolism (PE) is the third most common cause of cardiovascular morbidity and mortality. The goal of this review is to discuss the most up-to-date literature on epidemiology, diagnosis, risk stratification, and management of acute PE. RECENT FINDINGS Despite an increase in annual incidence rate of PE in the United States and development of multiple advanced therapies for treatment of acute PE, PE-related mortality is not consistently decreasing across populations. Although multiple risk stratification schemes have been developed, it is still unclear which advanced therapy should be used for the individual patient and optimal timing. Fortunately, multiple randomized clinical trials are underway to answer these questions. Nevertheless, up to 50% of patients have persistent reduced quality of life 6 months after acute PE, termed post-PE syndrome. Despite advances in therapeutic options for management of acute PE, many questions remain unanswered, including optimal risk stratification and management of acute PE.
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Affiliation(s)
- Stanislav Henkin
- Gonda Vascular Center, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Francisco Ujueta
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alyssa Sato
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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9
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Cavallino C, Franzino M, Abdirashid M, Maltese L, Bacci E, Rametta F, Ugo F. Novel Challenges and Therapeutic Options for Pulmonary Embolism and Deep Vein Thrombosis. J Pers Med 2024; 14:885. [PMID: 39202076 PMCID: PMC11355608 DOI: 10.3390/jpm14080885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/23/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024] Open
Abstract
Acute pulmonary embolism (PE), often resulting from deep vein thrombosis (DVT), is the third most frequent cause of cardiovascular death and is associated with increasing incidence, causing considerable morbidity and mortality. This review aims to evaluate the efficacy, safety, and outcomes of treatment options in the management of acute PE and DVT, encompassing both established and emerging technologies, such as catheter-directed thrombolysis, aspiration thrombectomy, and other endovascular techniques. A comprehensive literature review was conducted, assessing clinical studies, trials, and case reports that detail the use of percutaneous interventions for PE and DVT and analyzing the advantages and disadvantages of each percutaneous system. Several percutaneous treatments have shown promising results, especially in cases where rapid thrombus resolution is critical, such as in high- and intermediate-high-risk patients. The incidence of major complications, such as bleeding, remains a consideration, though it is generally manageable with proper patient selection and technique. It is fundamentally important to tailor the specific treatment strategy to the clinical and anatomical characteristics of each patient. Percutaneous treatments for acute PE and DVT represent valuable options in the therapeutic arsenal, offering enhanced outcomes in appropriately selected patients. Ongoing advancements in technology and technique, along with comprehensive clinical trials, are essential to further define the role and optimize the use of these interventions.
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Affiliation(s)
- Chiara Cavallino
- Cardiology Division, Sant’Andrea Hostpital, 13100 Vercelli, Italy; (M.F.); (M.A.); (L.M.); (E.B.); (F.R.); (F.U.)
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10
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Noman A, Stegman B, DuCoffe AR, Bhat A, Hoban K, Bunte MC. Episode Care Costs Following Catheter-Directed Reperfusion Therapies for Pulmonary Embolism: A Literature-Based Comparative Cohort Analysis. Am J Cardiol 2024; 225:178-189. [PMID: 38871160 DOI: 10.1016/j.amjcard.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/17/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
This analysis aimed to estimate 30-day episode care costs associated with 3 contemporary endovascular therapies indicated for treatment of pulmonary embolism (PE). Systematic literature review was used to identify clinical research reporting costs associated with invasive PE care and outcomes for ultrasound-accelerated thrombolysis (USAT), continuous-aspiration mechanical thrombectomy (CAMT), and volume-controlled-aspiration mechanical thrombectomy (VAMT). Total episode variable care costs were defined as the sum of device costs, variable acute care costs, and contingent costs. Variable acute care costs were estimated using methodology sensitive to periprocedural and postprocedural resource allocation unique to the 3 therapies. Contingent costs included expenses for thrombolytics, postprocedure bleeding events, and readmissions through 30 days. Through February 28, 2023, 70 sources were identified and used to inform estimates of 30-day total episode variable costs. Device costs for USAT, CAMT, and VAMT were the most expensive single component of total episode variable costs, estimated at $5,965, $10,279, and $11,901, respectively. Costs associated with catheterization suite utilization, intensive care, and hospital length of stay, along with contingent costs, were important drivers of total episode costs. Total episode variable care costs through 30 days were $19,146, $20,938, and $17,290 for USAT, CAMT, and VAMT, respectively. In conclusion, estimated total episode care costs after invasive treatment for PE are heavily influenced by device expense, in-hospital care, and postacute care complications. Regardless of device cost, strategies that avoid thrombolytics, reduce the need for intensive care unit care, shorten length of stay, and reduce postprocedure bleeding and 30-day readmissions contributed to the lowest episode costs.
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Affiliation(s)
- Anas Noman
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Brian Stegman
- Department of Cardiology, CentraCare Heart and Vascular Center, St. Cloud, Minnesota
| | - Aaron R DuCoffe
- Department of Radiology, Inova Health System, Fairfax, Virginia
| | - Ambarish Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri
| | - Kyle Hoban
- Department of Scientific Affairs, Inari Medical Inc, Irvine, California
| | - Matthew C Bunte
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Cardiology, Saint Luke's Hospital of Kansas City, Kansas City, Missouri.
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11
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Vrettou CS, Dima E, Karela NR, Sigala I, Korfias S. Severe Traumatic Brain Injury and Pulmonary Embolism: Risks, Prevention, Diagnosis and Management. J Clin Med 2024; 13:4527. [PMID: 39124793 PMCID: PMC11313609 DOI: 10.3390/jcm13154527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Severe traumatic brain injury (sTBI) is a silent epidemic, causing approximately 300,000 intensive care unit (ICU) admissions annually, with a 30% mortality rate. Despite worldwide efforts to optimize the management of patients and improve outcomes, the level of evidence for the treatment of these patients remains low. The concomitant occurrence of thromboembolic events, particularly pulmonary embolism (PE), remains a challenge for intensivists due to the risks of anticoagulation to the injured brain. We performed a literature review on sTBI and concomitant PE to identify and report the most recent advances on this topic. We searched PubMed and Scopus for papers published in the last five years that included the terms "pulmonary embolism" and "traumatic brain injury" in their title or abstract. Exclusion criteria were papers referring to children, non-sTBI populations, and post-acute care. Our search revealed 75 papers, of which 38 are included in this review. The main topics covered include the prevalence of and risk factors for pulmonary embolism, the challenges of timely diagnosis in the ICU, the timing of pharmacological prophylaxis, and the treatment of diagnosed PE.
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Affiliation(s)
- Charikleia S. Vrettou
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Effrosyni Dima
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Nina Rafailia Karela
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Ioanna Sigala
- First Department of Critical Care Medicine, Evangelismos Hospital, Medical School, National & Kapodistrian University of Athens, 10676 Athens, Greece (N.R.K.)
| | - Stefanos Korfias
- Department of Neurosurgery, Evaggelismos General Hospital of Athens, 10676 Athens, Greece
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12
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Buda K, Jensen J, Knickelbine T, Gebhard T, Engstrom B, Saxena R. Aspiration Thrombectomy for Intermediate-Risk Pulmonary Embolism. CJC Open 2024; 6:1021-1024. [PMID: 39211759 PMCID: PMC11357774 DOI: 10.1016/j.cjco.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/25/2024] [Indexed: 09/04/2024] Open
Affiliation(s)
- Kevin Buda
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Joseph Jensen
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | | | - Thomas Gebhard
- Department of Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Bjorn Engstrom
- Department of Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Retu Saxena
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
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13
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Sutedja JC, Tjandra DC, Oden GF, DE Liyis BG. Resveratrol as an adjuvant prebiotic therapy in the management of pulmonary thromboembolism. Minerva Cardiol Angiol 2024; 72:416-425. [PMID: 38305013 DOI: 10.23736/s2724-5683.23.06455-4] [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: 02/03/2024]
Abstract
Pulmonary thromboembolism (PTE) presents a grave threat to patient lives, often marked by arterial occlusion in the pulmonary vasculature, frequently stemming from deep vein thrombosis (DVT). While current anticoagulant therapies offer temporary relief, they fall short of addressing the long-term management of PTE. Notably, PTE-associated mortality rates continue to rise annually, positioning it as a crucial concern within the cardiovascular landscape. An intriguing suspect underlying compromised prognoses is the intricate interplay between the gut microbiome and PTE outcomes. The gut-derived metabolite, trimethylamine N-oxide (TMAO), has emerged as a direct contributor to accelerated thrombogenesis, thereby heightening PTE susceptibility. In pursuit of remedies, research has delved into diverse prebiotic and probiotic interventions, with Resveratrol (RSV) emerging as a promising candidate. This paper explores the potential of RSV, a polyphenolic compound, as an adjuvant prebiotic therapy. The proposed therapeutic approach not only augments anticoagulant potency through strategic pharmacokinetic interactions but also introduces a novel avenue for attenuating future PTE incidents through deliberate gut microbiome modulation. RSV's multifaceted attributes extend beyond its role in PTE prevention. Recognized for its anti-inflammatory, antioxidant, and cardioprotective properties, RSV stands as a versatile therapeutic candidate. It exhibits the ability to curtail platelet aggregation, augment warfarin bioavailability, and mitigate pulmonary arterial wall thickening - an ensemble of effects that substantiate its potential as an adjunct prebiotic for PTE patients. This literature review weaves together the latest insights, culminating in a compelling proposition: RSV is an instrumental player in the trajectory of PTE management.
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Affiliation(s)
- Jane C Sutedja
- Faculty of Medicine, Udayana University, Denpasar, Indonesia -
| | - David C Tjandra
- Faculty of Medicine, Udayana University, Denpasar, Indonesia
| | - Gwyneth F Oden
- Faculty of Medicine, Udayana University, Denpasar, Indonesia
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14
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Villalba L, Deen R, Tonson-Older B, Costello C. Single-session catheter-directed lysis using adjunctive clot fragmentation with power pulse spray only is a fast, safe, and effective option for acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101899. [PMID: 38677551 DOI: 10.1016/j.jvsv.2024.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Single-session, catheter-directed thrombolysis (CDT) with adjunctive power pulse spray (PPS) only, without thrombectomy, was evaluated for its safety and effectiveness. We performed a single-center, retrospective analysis of prospectively collected data. METHODS Patients with high-risk or intermediate-risk pulmonary embolism (PE) who met the inclusion criteria and underwent a single session of CDT-PPS were included in the study. The primary outcomes assessed were technical and clinical success and major adverse events. Secondary outcomes included effectiveness based on pre- and postintervention clinical examination, radiographic findings, and reversal of right ventricular dysfunction at 48 hours and 4 weeks after discharge on echocardiography and computed tomography pulmonary angiography. The length of stay in the intensive care unit and overall admission were also analyzed. A return to premorbid exercise tolerance was evaluated at 12 months after the procedure. RESULTS Between May 2016 and January 2023, 104 patients at the Wollongong Hospital were diagnosed with high- or intermediate-risk PE and underwent CDT-PPS. Of the 104 patients, 49 (47%) were considered to have high-risk PE and 55 (53%) intermediate-risk PE. Eleven patients (11%) had absolute contraindications and 49 patients (47%) had relative contraindications to systemic thrombolysis. Technical success was achieved in 102 patients (98%). Survival was 99% at 48 hours, 96% at 4 weeks, and 91% at 12 months. At 4 weeks, echocardiography showed 98% of patients had no evidence of right heart dysfunction, and computed tomography pulmonary angiography showed complete resolution of PE in 72%. There were no major adverse events at 48 hours. The median intensive care unit length of stay was 1 day, and the overall length of stay was 6 days. At 12 months, 96% had returned to their premorbid status. CONCLUSIONS The CDT-PPS technique is fast, safe, and effective in the treatment of high- and intermediate-risk PE, even in patients with a high bleeding risk, and should be considered as first-line management when the skills and resources are available. Further multicenter prospective studies are needed to corroborate these results.
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Affiliation(s)
- Laurencia Villalba
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia; Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Intensive Care Unit, Department of Vascular Surgery, Vascular Care Centre, Wollongong, New South Wales, Australia.
| | - Raeed Deen
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Brendan Tonson-Older
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Cartan Costello
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
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15
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Gostev AA, Valiev E, Zeidlits GA, Shmidt EA, Osipova OS, Cheban AV, Saaya SB, Barbarash OL, Karpenko AA. Treatment of acute pulmonary embolism after catheter-directed thrombolysis with dabigatran vs warfarin: Results of a multicenter randomized RE-SPIRE trial. J Vasc Surg Venous Lymphat Disord 2024; 12:101848. [PMID: 38346475 DOI: 10.1016/j.jvsv.2024.101848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Thrombolytic therapy is effective method in the high-risk acute pulmonary embolism (PE) treatment. Reduced-dose thrombolysis (RDT) plus oral anticoagulation therapy is effective and safe method in the moderate and severe PE treatment. It is leading to good early and intermediate-term outcomes. In the RE-COVER and RE-COVER II studies, dabigatran showed similar effectiveness as warfarin in the treatment of acute PE. Dabigatran leads to fewer hemorrhagic complications and is not inferior in efficacy to warfarin in the prevention of PE after mechanical fragmentation and RDT (catheter-directed treatment [CDT]+RDT) in patients with high and intermediate to high PE risk. We sought to evaluate the efficacy and safety (incidence of clinically significant recurrence of venous thromboembolic complications and deaths) during a 6-month course of treatment with dabigatran or warfarin in patients with high and intermediate to high acute PE risk after endovascular mechanical thrombus fragmentation procedure with RDT (CDT+RDT). METHODS The RE-SPIRE is a prospective, multicenter randomized double-arm study. Over a 5-year period, 66 consecutive patients with symptomatic high and intermediate to high PE risk after endovascular mechanical thrombus fragmentation procedure with RDT (CDT+RDT) were randomized into two groups within the next 48 hours. The first group continued treatment with dabigatran 150 mg twice a day for 6 months; the second group continued treatment with warfarin under the control of international normalized ratio (2.0-3.0) for 6 months. Both groups received low molecular weight heparins for 2 days after surgery. Then, group 1 continued to receive low molecular-weight-heparin for 5 to 7 days, followed by a switch to dabigatran at a dosage of 150 mg two times a day. Group 2 received both low-molecular-weight heparin and warfarin up to an international normalized ratio of >2.0, followed by heparin withdrawal. The follow-up period was 6 months. RESULTS There were 63 patients who completed the study (32 in the dabigatran group and 31 in the warfarin group). In both groups, there was a statistically significant decrease in the mean pulmonary artery pressure. The mean pulmonary artery pressure at the 6-month follow-up after surgery was 24 mm Hg (interquartile range, 20.3-29.25 mm Hg) in the dabigatran group and 23 mm Hg (interquartile range, 20.0-26.3 mm Hg) in the warfarin group. The groups did not differ statistically in the deep vein thrombosis dynamics. Partial recanalization occurred in 52.0% vs 73.1% in the dabigatran and warfarin groups, respectively (P = .15). Complete recanalization occurred in 28.0% vs 19.2% in the dabigatran and warfarin groups, respectively (P = .56). The groups did not differ in the frequency of major bleeding events according to the International Society for Thrombosis and Hemostasis (0% vs 3.2% in the dabigatran and warfarin groups, respectively; P = 1.00). However, there were more nonmajor bleeding events in the warfarin group than in the dabigatran group (16.1% vs 0%, respectively; P = .02). CONCLUSIONS The results of the study show that dabigatran is comparable in effectiveness to warfarin. Dabigatran has greater safety in comparison with warfarin in the occurrence of all cases of bleeding in the postoperative and long-term periods. Thus, dabigatran may be recommended for the treatment and prevention of PE after CDT with RDT in patients with high and intermediate to high PE risk.
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Affiliation(s)
- Alexander A Gostev
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation.
| | - Emin Valiev
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Galina A Zeidlits
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Evgeniya A Shmidt
- Scientific and Research Institute of Complex Cardiovascular Problems, Kemerovo, Russian Federation
| | - Olesya S Osipova
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Alexey V Cheban
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Shoraan B Saaya
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Olga L Barbarash
- Scientific and Research Institute of Complex Cardiovascular Problems, Kemerovo, Russian Federation
| | - Andrey A Karpenko
- Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
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16
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Silveira P, McCloskey J, Kassar M. Thrombolysis of incidental pulmonary embolism in a stroke patient. Radiol Case Rep 2024; 19:2600-2602. [PMID: 38645948 PMCID: PMC11026682 DOI: 10.1016/j.radcr.2024.03.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/09/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Both acute ischemic stroke (AIS) and pulmonary embolism (PE) are major causes of morbidity and mortality, with overlapping risk factors. Incidental or silent PE therefore may be discovered during an AIS work-up. Thrombolytic therapy is considered first-line therapy for eligible patients with AIS. We present the case of an 88-year-old man with an AIS, who was incidentally found to have a PE, and then received thrombolytic therapy leading to favorable outcomes in both conditions.
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Affiliation(s)
- Patrick Silveira
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
| | - Justin McCloskey
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
| | - Mohammad Kassar
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
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17
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Tébar D, Jurado-Román A, Jiménez-Valero S, Galeote G, Gonzálvez A, Rivero B, García A, Añón Elizalde JM, Lorenzo A, Fernández Capitán C, Torres R, Soto C, Alcolea S, Rosillo S, Caro Codón J, Arbas E, Tejera F, Plaza I, Boscá L, Moreno R. Percutaneous pulmonary thrombectomy with aspiration catheters in patients with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00558-X. [PMID: 38960828 DOI: 10.1016/j.carrev.2024.06.020] [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: 01/26/2024] [Revised: 05/25/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND High-risk Pulmonary Embolism (PE) mortality remains very high. Systemic thrombolysis is effective but carries significant complications and contraindications related to the hemorrhagic risk. Percutaneous thrombectomy using aspiration catheters may be an alternative in patients with a high bleeding risk. OBJECTIVE This study aimed to evaluate the results of catheter-directed thrombectomy using aspiration dedicated catheters in patients with high-risk PE and absolute contraindication to systemic thrombolysis, with specific focus on procedural success, safety, and in-hospital outcomes. METHODS A prospective study enrolled all consecutive patients diagnosed with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis, who underwent percutaneous pulmonary thrombectomy using dedicated aspiration catheters. The study documented the effectiveness and complications of the procedure, as well as patient outcomes at discharge and during the follow-up period. RESULTS Thirteen patients underwent percutaneous pulmonary thrombectomy using aspiration dedicated catheters. The procedure was successful for all patients, resulting in hemodynamic and respiratory improvement within the first 24 h. No deaths attributable to cardiovascular or respiratory causes occurred during admission or follow-up. Furthermore, no serious adverse events or complications were reported during the procedure or hospitalization. CONCLUSIONS Percutaneous pulmonary thrombectomy with dedicated aspiration catheters in patients with high-risk pulmonary embolism and contraindications to systemic thrombolysis was associated with excellent clinical results and low rate of complications.
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Affiliation(s)
- Daniel Tébar
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain.
| | - Alfonso Jurado-Román
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Santiago Jiménez-Valero
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Guillermo Galeote
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Ariana Gonzálvez
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Borja Rivero
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Andoni García
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
| | | | - Alicia Lorenzo
- Thromboembolic Disease Unit, Internal Medicine. La Paz University Hospital, Madrid, Spain
| | | | - Rosario Torres
- Emergency Department, La Paz University Hospital, Madrid, Spain
| | - Clara Soto
- Pulmonary Hypertension Unit, La Paz University Hospital, Madrid, Spain
| | - Sergio Alcolea
- Pulmonary Hypertension Unit, La Paz University Hospital, Madrid, Spain
| | - Sandra Rosillo
- Cardiac Intensive Care Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Juan Caro Codón
- Cardiac Intensive Care Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Emilio Arbas
- Cardiac Intensive Care Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Fernando Tejera
- Intensive Care Unit, Infanta Cristina University Hospital, Madrid, Spain
| | - Ignacio Plaza
- Cardiology Department, Infanta Sofia University Hospital, Madrid, Spain
| | - Lisardo Boscá
- Hospital La Paz Research Foundation (IdiPAZ), Madrid, Spain; Network Center for Cardiovascular Diseases Research (CIBERcv), Spain; Sols-Morreale Biomedical Research Institute (CSIC-UAM), Spain; Autonomous University of Madrid, Madrid, Spain
| | - Raúl Moreno
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain; Hospital La Paz Research Foundation (IdiPAZ), Madrid, Spain
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18
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Ito WD. [Interventional therapy of pulmonary embolism - update]. Dtsch Med Wochenschr 2024; 149:679-683. [PMID: 38781990 DOI: 10.1055/a-2133-8319] [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: 05/25/2024]
Abstract
Several catheter-based systems have been developed for interventional recanalization of pulmonary embolism. These include local ultrasound assisted thrombolysis (EKOS), in-toto-thrombectomy via retriever and aspiration system (FlowTriever) and the Indigo mechanical aspiration system. Safety and efficacy in the removal of thrombus have been demonstrated for all systems. Interventional recanalization strategies for high- and intermediate-high risk pulmonary embolism are potentially more effective in the removal of thrombus and restoration of right heart function than systemic thrombolysis with a lower risk of major bleeding complications. Preliminary data from registries and observational studies are very promising whereas the evidence for systemic thrombolysis treatment in high and intermediate-high risk pulmonary embolism is low. Randomized controlled clinical trials are currently performed comparing catheter based interventional therapies to systemic thrombolysis for the treatment of intermediate-high risk pulmonary embolisms. Primary outcome measurements include mortality, hemodynamic collapse, and major bleedings. Results are expected in 2025. The introduction of interventional therapies for pulmonary embolism was accompanied by an increased awareness of the complexity of pulmonary embolism management. The need for specialized interdisciplinary pulmonary embolism response teams (PERT-teams) and a well-structured approach including a PDCA cycle was recognized.
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Affiliation(s)
- Wulf D Ito
- Herz-und Gefäßzentrum Oberallgäu-Kempten, Klinikverbund Allgäu gGmbH, Immenstadt
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19
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Pizzi R, Cimini LA, Ageno W, Becattini C. Direct Oral Anticoagulants for Pulmonary Embolism. Hamostaseologie 2024; 44:206-217. [PMID: 38467144 DOI: 10.1055/a-2105-8736] [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: 03/13/2024] Open
Abstract
Venous thromboembolism (VTE) is the third most common cardiovascular disease. For most patients, the standard of treatment has long consisted on low-molecular-weight heparin followed by vitamin K antagonists, but a number of clinical trials and, subsequently, post-marketing studies have shown that direct oral anticoagulants (DOACs) with or without lead-in heparin therapy are effective alternatives with fewer adverse effects. This evidence has led to important changes in the guidelines on the treatment of VTE, including pulmonary embolism (PE), with the DOACs being now recommended as the first therapeutic choice. Additional research has contributed to identifying low-risk PE patients who can benefit from outpatient management or from early discharge from the emergency department with DOAC treatment. There is evidence to support the use of DOACs in intermediate-risk PE patients as well as in high-risk patients receiving thrombolytic treatment. The use of DOACs has also been proven to be safe and effective in special populations of PE patients, such as patients with renal impairment, liver impairment, and cancer.
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Affiliation(s)
- Roberto Pizzi
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ludovica Anna Cimini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cecilia Becattini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
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20
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Monteleone P, Patel A, Paul J. Evidence-Based Update on Transcatheter Therapies for Pulmonary Embolism. Curr Cardiol Rep 2024; 26:475-482. [PMID: 38656585 DOI: 10.1007/s11886-024-02060-3] [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] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Pulmonary embolism (PE) remains a leading cause of cardiovascular morbidity and mortality. Multiple new therapies are in development and under study to improve our contemporary care of patients with PE. We review and compare here these novel therapeutics and technologies. RECENT FINDINGS Multiple novel therapeutic devices have been developed and are under active study. This work has advanced the care of patients with intermediate and high-risk PE. Novel therapies are improving care of complex PE patients. These have inspired large multicenter international randomized controlled trials that are actively recruiting patients to advance the care of PE. These studies will work towards advancing guidelines for clinical care of patients with PE.
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Affiliation(s)
- Peter Monteleone
- Department of Medicine, University of Texas at Austin Dell School of Medicine, Austin, USA.
- Ascension Texas Cardiovascular, Austin, TX, USA.
| | - Akash Patel
- Department of Medicine, University of Texas at Austin Dell School of Medicine, Austin, USA
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21
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Gunaga S, Fourtounis JV, Swan KW, Butler SP, Al Hage A. Multi-organ Thromboembolic Crisis: A Case Report of Concomitant Stroke, Myocardial Infarction, and Pulmonary Embolism. Cureus 2024; 16:e63288. [PMID: 39070318 PMCID: PMC11283252 DOI: 10.7759/cureus.63288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/30/2024] Open
Abstract
Management of acute coronary syndrome (ACS), cerebrovascular accident (CVA), and pulmonary embolism (PE) necessitates prompt intervention, as delayed treatment may lead to severe consequences. Each of these conditions presents significant challenges and carries a high risk of morbidity and mortality. We present the case of an 86-year-old female with a history of stage 4 urothelial carcinoma metastasized to the lungs, who presented to the emergency department (ED) with acute ischemic stroke (AIS), ST-segment elevation myocardial infarction (STEMI), and bilateral PE. We propose the term "multi-organ thromboembolic crisis" (MOTEC) to streamline the communication and management approach for patients experiencing critical thromboembolic events affecting multiple organ systems.
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Affiliation(s)
- Satheesh Gunaga
- Emergency Medicine, Henry Ford Wyandotte Hospital/Envision Healthcare/Michigan State University College of Osteopathic Medicine, Wyandotte, USA
| | | | - Kirby W Swan
- Emergency Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, USA
| | - Seth P Butler
- Emergency Medicine, University at Buffalo, Buffalo, USA
| | - Abe Al Hage
- Emergency Medicine, Henry Ford Wyandotte Hospital/Envision Healthcare/Michigan State University College of Osteopathic Medicine, Wyandotte, USA
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22
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Chopard R, Morillo R, Meneveau N, Jiménez D. Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence. Hamostaseologie 2024; 44:182-192. [PMID: 38531394 DOI: 10.1055/a-2215-9003] [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: 03/28/2024] Open
Abstract
High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
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23
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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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Mouawad NJ. Catheter Interventions for Pulmonary Embolism: Mechanical Thrombectomy Versus Thrombolytics. Methodist Debakey Cardiovasc J 2024; 20:36-48. [PMID: 38765215 PMCID: PMC11100542 DOI: 10.14797/mdcvj.1344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/11/2024] [Indexed: 05/21/2024] Open
Abstract
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.
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Loh TM. Intervention Versus Medical Management of Pulmonary Embolism. Methodist Debakey Cardiovasc J 2024; 20:13-18. [PMID: 38765214 PMCID: PMC11100531 DOI: 10.14797/mdcvj.1351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/12/2024] [Indexed: 05/21/2024] Open
Abstract
With a multitude of options for pulmonary embolism management, we review the most common diagnostic tools available for assessing risk as well as how each broad risk category is typically treated. Right heart dysfunction is the cornerstone for triage of these patients and should be the focus for decision-making, especially in challenging patients. We aim to provide a modern, clinical perspective for PE management in light of the multitude of intervention options.
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Affiliation(s)
- Thomas M. Loh
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
- Houston Methodist, The Woodlands, Texas, US
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Donovan KM. Pulmonary Embolism Triage: When to Do What. Methodist Debakey Cardiovasc J 2024; 20:65-67. [PMID: 38765217 PMCID: PMC11100534 DOI: 10.14797/mdcvj.1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 05/21/2024] Open
Abstract
Anticoagulation has been the standard therapy for treating pulmonary embolism. However, newly developed pharmacological and interventional treatment options have been shown to provide benefit for certain patient populations, depending on how they present. This column highlights the use of massive pulmonary embolism risk stratification in determining the presence of cor pulmonale and offers several key points to remember when caring for patients with a pulmonary embolism.
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Affiliation(s)
- Kathryn M. Donovan
- Department of Cardiovascular Surgery, Houston Methodist, The Woodlands, Texas, US
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Al Hennawi H, Khedr A, Khan MK, Ashraf MT, Sohail A, Mathbout L, Eissa A, Mathbout M, Klugherz B. Safety and efficacy of clot-dissolving therapies for submassive pulmonary embolism: A network meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:73-81. [PMID: 38176962 DOI: 10.1016/j.carrev.2023.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a serious condition that needs quick and effective treatment. Anticoagulation therapy is the usual care for most PE patients but may not work well for higher-risk ones. Thrombolysis breaks the clot and improves blood flow. It can be given systemically or locally. Ultrasound-assisted catheter-directed thrombolysis (USAT) is a new technique that boosts clot-busting drugs. This network meta-analysis compares death, bleeding, and benefits of four treatments in acute submassive PE. METHODS We comprehensively searched relevant databases up to July 2023 for RCTs. The outcomes encompassed all-cause mortality, major and minor bleeding, PE recurrence, and hospital stay duration. Bayesian network meta-analysis computed odds ratios (OR) and 95 % CI estimates. RESULTS In this network meta-analysis of 23 RCTs involving 2521 PE patients, we found that SCDT had the most favorable performance for mortality, as it had the lowest odds ratio (OR) among the four interventions (OR 5.41e-42; 95 % CI, 5.68e-97, 1.37e-07). USAT had the worst performance for major bleeding, as it had the highest OR among the four interventions (OR 4.73e+04; 95 % CI, 1.65, 9.16e+13). SCDT also had the best performance for minor bleeding, as it had the lowest OR among the four interventions (OR 5.68e-11; 95 % CI, 4.97e-25, 0.386). CONCLUSION Our meta-analysis suggests that SCDT is the most effective treatment intervention in improving the risks of All-cause mortality and bleeding. Thrombolytic therapy helps in improving endpoints including the risk of PE recurrence and the duration of hospital stay.
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Affiliation(s)
| | | | | | | | - Affan Sohail
- Dow University of Health Science, Karachi, Pakistan
| | - Lein Mathbout
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [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] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med 2024; 52:729-742. [PMID: 38165776 DOI: 10.1097/ccm.0000000000006162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
OBJECTIVES Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN Multicenter retrospective observational study. SETTING Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively ( p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.
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Affiliation(s)
- Roman Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - David M Tierney
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
- Department of Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Ranran Xia
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Abbey Sidebottom
- Department of Care Delivery Research, Allina Health, Minneapolis, MN
| | - Brandon M Wiley
- Department of Medicine, Los Angeles General Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ivan Khapov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
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.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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Ley L, Messmer F, Vaisnora L, Ghofrani HA, Bandorski D, Kostrzewa M. Electrocardiographic Changes after Endovascular Mechanical Thrombectomy in a Patient with Pulmonary Embolism-A Case Report and Literature Review. J Clin Med 2024; 13:2548. [PMID: 38731076 PMCID: PMC11084833 DOI: 10.3390/jcm13092548] [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: 03/05/2024] [Revised: 03/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
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.
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Affiliation(s)
- Lukas Ley
- Department of Radiology, Baden Cantonal Hospital, 5404 Baden, Switzerland; (F.M.); (M.K.)
- Campus Kerckhoff, Justus-Liebig-University Giessen, 61231 Bad Nauheim, Germany
| | - Florian Messmer
- Department of Radiology, Baden Cantonal Hospital, 5404 Baden, Switzerland; (F.M.); (M.K.)
| | - Lukas Vaisnora
- Department of Cardiology, Baden Cantonal Hospital, 5404 Baden, Switzerland;
| | | | - Dirk Bandorski
- Faculty of Medicine, Semmelweis University Campus Hamburg, 20099 Hamburg, Germany;
| | - Michael Kostrzewa
- Department of Radiology, Baden Cantonal Hospital, 5404 Baden, Switzerland; (F.M.); (M.K.)
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Guarnieri G, Constantin FD, Pedrazzini G, Ruffino MA, Sürder D, Petrino R, Zucconi EC, Gabutti L, Ogna A, Balestra B, Valgimigli M. Integrating Pharmacomechanical Treatments for Pulmonary Embolism Management within a Hub-and-Spoke System in the Swiss Ticino Region. J Clin Med 2024; 13:2457. [PMID: 38730985 PMCID: PMC11084835 DOI: 10.3390/jcm13092457] [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: 02/27/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
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.
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Affiliation(s)
- Gianluca Guarnieri
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Filip David Constantin
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
| | - Giovanni Pedrazzini
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
| | - Maria Antonella Ruffino
- Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (M.A.R.); (R.P.); (E.C.Z.)
| | - Daniel Sürder
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
| | - Roberta Petrino
- Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (M.A.R.); (R.P.); (E.C.Z.)
| | - Enrico Carlo Zucconi
- Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (M.A.R.); (R.P.); (E.C.Z.)
| | - Luca Gabutti
- Ospedale Regionale di Bellinzona e Valli, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland;
| | - Adam Ogna
- Ospedale Regionale di Locarno, Ente Ospedaliero Cantonale, 6600 Locarno, Switzerland;
| | - Brenno Balestra
- Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland;
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
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Mohr K, Hobohm L, Kaier K, Farmakis IT, Valerio L, Barco S, Abele C, Münzel T, Neusius T, Konstantinides S, Binder H, Keller K. Drivers and recent trends of hospitalisation costs related to acute pulmonary embolism. Clin Res Cardiol 2024:10.1007/s00392-024-02437-y. [PMID: 38565711 DOI: 10.1007/s00392-024-02437-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIMS The socio-economic burden imposed by acute pulmonary embolism (PE) on European healthcare systems is largely unknown. We sought to determine temporal trends and identify cost drivers of hospitalisation for PE in Germany. METHODS AND RESULTS We analysed the totality of reimbursed hospitalisation costs in Germany (G-DRG system) in the years 2016-2020. Overall, 484 884 PE hospitalisations were coded in this period. Direct hospital costs amounted to a median of 3572 (IQR, 2804 to 5869) euros, resulting in average total reimbursements of 710 million euros annually. Age, PE severity, comorbidities and in-hospital (particularly bleeding) complications were identified by multivariable logistic regression as significant cost drivers. Use of catheter-directed therapy (CDT) constantly increased (annual change in the absolute proportion of hospitalisations with CDT + 0.40% [95% CI + 0.32% to + 0.47%]; P < 0.001), and it more than doubled in the group of patients with severe PE (28% of the entire population) over time. Although CDT use was overall associated with increased hospitalisation costs, this association was no longer present (adjusted OR 1.02 [0.80-1.31]) in patients with severe PE and shock; this was related, at least in part, to a reduction in the median length of hospital stay (for 14.0 to 8.0 days). CONCLUSIONS We identified current and emerging cost drivers of hospitalisation for PE, focusing on severe disease and intermediate/high risk of an adverse early outcome. The present study may inform reimbursement decisions by policymakers and help to guide future health economic analysis of advanced treatment options for patients with PE.
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Affiliation(s)
- Katharina Mohr
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Christina Abele
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Thomas Neusius
- Wiesbaden Business School, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Ying K, Xin W, Xu Y, Lv D, Zhu H, Li Y, Xu W, Yan C, Li Y, Cheng H, Chen E, Ma G, Zhang X, Ke Y. NanoSHP099-Targeted SHP2 Inhibition Boosts Ly6C low Monocytes/Macrophages Differentiation to Accelerate Thrombolysis. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2308166. [PMID: 38247197 PMCID: PMC10987109 DOI: 10.1002/advs.202308166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/06/2024] [Indexed: 01/23/2024]
Abstract
Tumor-associated thrombus (TAT) accounts for a high proportion of venous thromboembolism. Traditional thrombolysis and anticoagulation methods are not effective due to various complications and contraindications, which can easily lead to patients dying from TAT rather than the tumor itself. These clinical issues demonstrate the need to research diverse pathways for adjuvant thrombolysis in antitumor therapy. Previously, the phenotypic and functional transformation of monocytes/macrophages is widely reported to be involved in intratribal collagen regulation. This study finds that myeloid deficiency of the oncogene SHP2 sensitizes Ly6Clow monocyte/macrophage differentiation and can alleviate thrombus organization by increasing thrombolytic Matrix metalloproteinase (MMP) 2/9 activities. Moreover, pharmacologic inhibition by SHP099, examined in mouse lung metastatic tumor models, reduces tumor and thrombi burden in tumor metastatic lung tissues. Furthermore, SHP099 increases intrathrombus Ly6Clow monocyte/macrophage infiltration and exhibits thrombolytic function at high concentrations. To improve the thrombolytic effect of SHP099, NanoSHP099 is constructed to achieve the specific delivery of SHP099. NanoSHP099 is identified to be simultaneously enriched in tumor and thrombus foci, exerting dual tumor-suppression and thrombolysis effects. NanoSHP099 presents a superior thrombus dissolution effect than that of the same dosage of SHP099 because of the higher Ly6Clow monocyte/macrophage proportion and MMP2/MMP9 collagenolytic activities in organized thrombi.
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Affiliation(s)
- Kejing Ying
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Wanghao Xin
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Yiming Xu
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Dandan Lv
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Huiqi Zhu
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Yeping Li
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Wangting Xu
- Department of RespiratoryFirst Affiliated HospitalSchool of MedicineZhejiang UniversityHangzhouChina
- Department of Pathology and Pathophysiologyand Department of Respiratory Medicine at Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouZhejiang310058China
| | - Chao Yan
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Yiqing Li
- Department of Pathology and PathophysiologyZhejiang University School of MedicineHangzhouZhejiang310058China
| | - Hongqiang Cheng
- Department of Pathology and PathophysiologyZhejiang University School of MedicineHangzhouZhejiang310058China
| | - Enguo Chen
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Guofeng Ma
- Department of Pulmonary and Critical Care MedicineRegional Medical Center for National Institute of Respiratory DiseasesSir Run Run Shaw HospitalSchool of MedicineZhejiang UniversityHangzhou310016China
| | - Xue Zhang
- Department of Pathology and Pathophysiologyand Department of Respiratory Medicine at Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouZhejiang310058China
| | - Yuehai Ke
- Department of Pathology and Pathophysiologyand Department of Respiratory Medicine at Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouZhejiang310058China
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Al-Terki H, Lauder L, Mügge A, Götzinger F, Elhakim A, Mahfoud F. Ultrasound-assisted endovascular thrombolysis versus large-bore thrombectomy in acute intermediate-high risk pulmonary embolism: The propensity-matched EKNARI cohort study. Catheter Cardiovasc Interv 2024; 103:758-765. [PMID: 38415891 DOI: 10.1002/ccd.30998] [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: 11/14/2023] [Revised: 02/01/2024] [Accepted: 02/16/2024] [Indexed: 02/29/2024]
Abstract
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.
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Affiliation(s)
- Hani Al-Terki
- Cardiology and Rhythmology Department, St-Josef Hospital, Bochum, Germany
| | - Lucas Lauder
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin , Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Andreas Mügge
- Cardiology and Rhythmology Department, St-Josef Hospital, Bochum, Germany
| | - Felix Götzinger
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin , Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Felix Mahfoud
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin , Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
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Janssens U. Intensive Care Treatment of Pulmonary Embolism: An Update Based on the Revised AWMF S2k Guideline. Hamostaseologie 2024; 44:119-127. [PMID: 38499185 DOI: 10.1055/a-2237-7428] [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: 03/20/2024] Open
Abstract
Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. The prognosis of affected patients depends on the clinical severity. Therefore, risk stratification is imperative for therapeutic decision-making. Patients with high-risk PE need intensive care. These include patients who have successfully survived resuscitation, with obstructive shock or persistent haemodynamic instability. Bedside diagnostics by means of sonographic procedures are of outstanding importance in this high-risk population. In addition to the treatment of hypoxaemia with noninvasive and invasive techniques, the focus is on drug-based haemodynamic stabilisation and usually requires the elimination or reduction of pulmonary vascular thrombotic obstruction by thrombolysis. In the event of a contraindication to thrombolysis or failure of thrombolysis, various catheter-based procedures for thrombus extraction and local thrombolysis are available today and represent an increasing alternative to surgical embolectomy. Mechanical circulatory support systems can bridge the gap between circulatory arrest or refractory shock and definitive stabilisation but are reserved for centres with the appropriate expertise. Therapeutic strategies for patients with intermediate- to high-risk PE in terms of reduced-dose thrombolytic therapy or catheter-based procedures need to be further evaluated in prospective clinical trials.
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Affiliation(s)
- Uwe Janssens
- Medical Clinic and Intensive Care Medicine, St. Antonius Hospital Eschweiler, Eschweiler, Germany
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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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Boberg E, Hedman A, Hollenberg J. Pulmonary embolism with paradoxical embolization to right coronary artery in the presence of a large patent foramen ovale: a case report. Eur Heart J Case Rep 2024; 8:ytae133. [PMID: 38617591 PMCID: PMC11014684 DOI: 10.1093/ehjcr/ytae133] [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: 02/06/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024]
Abstract
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.
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Affiliation(s)
- Erik Boberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Anders Hedman
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
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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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Weekes AJ, Trautmann A, Hambright PL, Ali S, Pikus AM, Wellinsky N, Goonan KL, Bradford S, O'Connell NS. Comparison of Treatment Approaches and Subsequent Outcomes within a Pulmonary Embolism Response Team Registry. Crit Care Res Pract 2024; 2024:5590805. [PMID: 38560480 PMCID: PMC10980543 DOI: 10.1155/2024/5590805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/19/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives To characterize the association between pulmonary embolism (PE) severity and bleeding risk with treatment approaches, outcomes, and complications. Methods Secondary analysis of an 11-hospital registry of adult ED patients treated by a PE response team (August 2016-November 2022). Predictors were PE severity and bleeding risk. The primary outcome was treatment approach: anticoagulation monotherapy vs. advanced intervention (categorized as "immediate" or "delayed" based on whether the intervention was received within 12 hours of PE diagnosis or not). Secondary outcomes were death, clinical deterioration, and major bleeding. Results Of the 1832 patients, 139 (7.6%), 977 (53.3%), and 9 (0.5%) were classified as high-risk, intermediate-high, intermediate-low, and low-risk severity, respectively. There were 94 deaths (5.1%) and 218 patients (11.9%) had one or more clinical deterioration events. Advanced interventions were administered to 86 (61.9%), 195 (27.6%), and 109 (11.2%) patients with high-risk, intermediate-high, and intermediate-low severity, respectively.Major bleeding occurred in 61/1440 (4.2%) on ACm versus 169/392 (7.6%) with advanced interventions (p <0.001): bleeding withcatheter-directed thrombolysiswas 19/145 (13.1%) versus 33/154(21.4%) with systemic thrombolysis,p= 0.07. High risk was twice as strong as intermediate-high risk for association with advanced intervention (OR: 5.3 (4.2 and 6.9) vs. 1.9 (1.6 and 2.2)). High risk (OR: 56.3 (32.0 and 99.2) and intermediate-high risk (OR: 2.6 (1.7 and 4.0)) were strong predictors of clinical deterioration. Major bleeding was significantly associated with advanced interventions (OR: 5.2 (3.5 and 7.8) for immediate, 3.3 (1.8 and 6.2)) for delayed, and high-risk PE severity (OR: 3.4 (1.9 and 5.8)). Conclusions Advanced intervention use was associated with high-acuity patients experiencing death, clinical deterioration, and major bleeding with a trend towards less bleeding with catheter-directed interventions versus systemic thrombolysis.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Ariana Trautmann
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Parker L. Hambright
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Shane Ali
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Angela M. Pikus
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Nicole Wellinsky
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kelly L. Goonan
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Sarah Bradford
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Chopard R, Bertoletti L, Piazza G, Jimenez D, Barillari G, Llamas P, Rubio CM, Aujayeb A, Monreal M, Meneveau N. External validation of the PE-SARD risk score for predicting early bleeding in acute pulmonary embolism in the RIETE Registry. Thromb Res 2024; 235:22-31. [PMID: 38295598 DOI: 10.1016/j.thromres.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/04/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024]
Abstract
INTRODUCTION The PE-SARD score (syncope, anemia, renal dysfunction) was developed to predict the risk of major bleeding in the acute phase of pulmonary embolism (PE). METHODS We analyzed data from 50,686 patients with acute PE included in the RIETE registry to externally validate the PE-SARD score. We calculated the overall reliability of the PE-SARD score, as well as discrimination and calibration for predicting the risk of major bleeding at 30 days. The performance of PE-SARD was compared to the BACS and PE-CH models. RESULTS During the first 30 days, 640 patients (1.3 %) had a major bleeding event. The incidence of major bleeding within 30 days was 0.6 % in the PE-SARD-defined low-risk group, 1.5 % in the intermediate-risk group, and 2.5 % in the high-risk group, for an OR of 2.22 (95 % CI, 2.02-2.43) for the intermediate-risk group (vs low-risk group), and 3.94 for the high-risk group (vs low-risk group). The corresponding sensitivity was 81.1 % (intermediate/high vs low risk), and specificity was 85.9 % (95 % CI, 85.8-86.1) (low/intermediate vs high risk). The applicability of PE-SARD was consistent across clinically relevant patient subgroups and over shorter time periods of follow-up (i.e., 3 and 7 days). The C-index was 0.654 and calibration was excellent. The PE-SARD bleeding score improved the major bleeding risk prediction compared with the BACS and PE-CH scores. CONCLUSIONS The PE-SARD score identifies PE patients with a higher risk of bleeding, which could assist providers for potentially adjusting PE management, in a framework of shared decision-making with individual patients.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France; EA3920, University of Franche-Comté, 25000 Besançon, France; F-CRIN, INNOVTE network, France.
| | - Laurent Bertoletti
- F-CRIN, INNOVTE network, France; Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, CIC 1408, Département of Médecine Vasculaire et Thérapeutique, 42055 Saint-Etienne, France
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | | | - Pilar Llamas
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Carmen Mª Rubio
- Department of Internal Medicine, Hospital Alto Guadalquivir Andújar, Jaén, Spain
| | - Avinash Aujayeb
- Northumbria Healthcare Foundation trust, Newcastle, United Kingdom
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Cátedra de Enfermedad Tromboembólica, Universidad Católica de Murcia, Murcia, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France; EA3920, University of Franche-Comté, 25000 Besançon, France; F-CRIN, INNOVTE network, France
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Murguia AR, Mukherjee D, Ojha C, Rajachandran M, Siddiqui TS, Nickel NP. Reduced-Dose Thrombolysis in Acute Pulmonary Embolism A Systematic Review. Angiology 2024; 75:208-218. [PMID: 37060258 DOI: 10.1177/00033197231167062] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality and the second-leading cause of death in cancer patients. The clinical efficacy of thrombolysis for acute PE has been proven, yet the therapeutic window seems narrow, and the optimal dosing for pharmaceutical reperfusion therapy has not been established. Higher doses of systemic thrombolysis inevitably associated with an incremental increase in major bleeding risk. To date, there is no high-quality evidence regarding dosing and infusion rates of thrombolytic agents to treat acute PE. Most clinical trials have focused on thrombolysis compared with anticoagulation alone, but dose-finding studies are lacking. Evidence is now emerging that lower-dose thrombolytic administered through a peripheral vein is efficacious in accelerating thrombolysis in the central pulmonary artery and preventing acute right heart failure, with reduced risk for major bleeding. The present review will systematically summarize the current evidence of low-dose thrombolysis in acute PE.
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Affiliation(s)
- Adrian Rojas Murguia
- Department of Internal Medicine, Texas Tech University Health Sciences Center of El Paso, Texas, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Chandra Ojha
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Manu Rajachandran
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Tariq S Siddiqui
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Nils P Nickel
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center of El Paso, Texas, TX, USA
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Sterling KM, Goldhaber SZ, Sharp AS, Kucher N, Jones N, Maholic R, Meneveau N, Zlotnick D, Sayfo S, Konstantinides SV, Piazza G. Prospective Multicenter International Registry of Ultrasound-Facilitated Catheter-Directed Thrombolysis in Intermediate-High and High-Risk Pulmonary Embolism (KNOCOUT PE). Circ Cardiovasc Interv 2024; 17:e013448. [PMID: 38264938 PMCID: PMC10942169 DOI: 10.1161/circinterventions.123.013448] [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: 07/19/2023] [Accepted: 12/14/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Prior clinical trials have demonstrated the efficacy of ultrasound-facilitated catheter-directed thrombolysis (USCDT) for the treatment of acute intermediate-risk pulmonary embolism (PE) using reduced thrombolytic doses and shorter infusion durations. However, utilization and safety of such strategies in broader PE populations remain unclear. The KNOCOUT PE (The EKoSoNic Registry of the Treatment and Clinical Outcomes of Patients With Pulmonary Embolism) registry is a multicenter international registry designed to study the treatment of acute PE with USCDT, with focus on safety outcomes. METHODS The KNOCOUT PE prospective cohort included 489 patients (64 sites internationally) with acute intermediate-high or high-risk PE treated with USCDT between March 2018 and June 2020. Principal safety outcomes were independently adjudicated International Society on Thrombosis and Haemostasis major bleeding at 72 hours post-treatment and mortality within 12 months of treatment. Additional outcomes included change in right ventricular/left ventricular ratio and quality of life measures over 12 months. RESULTS Mean alteplase (r-tPA [recombinant tissue-type plasminogen activator]) infusion duration was 10.5 hours. Mean total r-tPA dose was 18.1 mg, with 31.0% of patients receiving ≤12 mg. Major bleeding events within 72 hours occurred in 1.6% (8/489) of patients. One patient experienced worsening of a preexisting subdural hematoma after USCDT and therapeutic anticoagulation, which ultimately required surgery. All-cause mortality at 30 days was 1.0% (5/489). Improvement in PE quality of life score was observed with a 41.1% (243/489, 49.7%) and 44.2% (153/489, 31.3%) mean relative reduction by 3 and 12 months, respectively. CONCLUSIONS In a prospective observational cohort study of patients with intermediate-high and high-risk PE undergoing USCDT, mean r-tPA dose was 18 mg, and the rates of major bleeding and mortality were low. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03426124.
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Affiliation(s)
| | - Samuel Z. Goldhaber
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.Z.G., G.P.)
| | - Andrew S.P. Sharp
- University Hospital of Wales and Cardiff University, United Kingdom (A.S.P.S.)
| | - Nils Kucher
- University Clinic of Angiology, University Hospital Zurich, Switzerland (N.K.)
| | - Noah Jones
- Mount Carmel Health System, Columbus, OH (N.J.)
| | - Robert Maholic
- University of Pittsburgh Medical Center Hamot, Erie, PA (R.M.)
| | | | - David Zlotnick
- University at Buffalo/Great Lakes Cardiovascular, NY (D.Z.)
| | - Sameh Sayfo
- Baylor Scott and White The Heart Hospital Plano, TX (S.S.)
| | | | - Gregory Piazza
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.Z.G., G.P.)
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Millington SJ, Aissaoui N, Bowcock E, Brodie D, Burns KEA, Douflé G, Haddad F, Lahm T, Piazza G, Sanchez O, Savale L, Vieillard-Baron A. High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med 2024; 50:195-208. [PMID: 38112771 DOI: 10.1007/s00134-023-07275-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.
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Affiliation(s)
- Scott J Millington
- Critical Care, The University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada
| | - Nadia Aissaoui
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université Paris Cité, Paris, France
| | - Emma Bowcock
- Department of Intensive Care, Nepean Hospital, University of Sydney, Sydney, Australia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford University, Stanford, CA, USA
| | - Tim Lahm
- Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Sanchez
- Service de pneumologie et soins intensifs, Hopital Européen Georges Pompidou, APHP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Université Paris Cité, Paris, France
| | - Laurent Savale
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, APHP, Boulogne-Billancourt, France.
- Inserm U1018, CESP, Universite Versailles Saint-Quentin en Yvelines, Guyancourt, France.
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45
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Santos-Ferreira C. Reperfusion therapy in high-risk pulmonary embolism: Underuse of a life-saving treatment is still a concern. Rev Port Cardiol 2024; 43:65-66. [PMID: 38128760 DOI: 10.1016/j.repc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
- Cátia Santos-Ferreira
- Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
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46
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Argyriou A, Vohra H, Chan J, Ahmed EM, Rajakaruna C, Angelini GD, Fudulu DP. Incidence and outcomes of surgical pulmonary embolectomy in the UK. Br J Surg 2024; 111:znae003. [PMID: 38230762 PMCID: PMC11167207 DOI: 10.1093/bjs/znae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Surgical pulmonary embolectomy is rarely used for the treatment of massive acute pulmonary embolism. The aim of this study was to assess the incidence and outcomes of this operation by undertaking a retrospective analysis of a large national registry in the UK. METHODS All acute pulmonary embolectomies performed between 1996 and 2018 were captured in the National Institute of Cardiovascular Outcomes Research central database. Trends in the number of operations performed during this interval and reported in-hospital outcomes were analysed retrospectively. Multivariable logistic regression was used to identify independent risk factors for in-hospital death. RESULTS All 256 patients treated surgically for acute pulmonary embolism during the study interval were included in the analysis. Median age at presentation was 54 years, 55.9% of the patients were men, 48.0% had class IV heart failure symptoms, and 37.5% had preoperative cardiogenic shock. The median duration of bypass was 73 min, and median cross-clamp time was 19 min. Cardioplegic arrest was used in 53.1% of patients. The median duration of hospital stay was 11 days. The in-hospital mortality rate was 25%, postoperative stroke occurred in 5.4%, postoperative dialysis was required in 16%, and the reoperation rate for bleeding was 7.5%. Risk-adjusted multivariable analysis revealed cardiogenic shock (OR 2.54, 95% c.i. 1.05 to 6.21; P = 0.038), preoperative ventilation (OR 5.85, 2.22 to 16.35; P < 0.001), and duration of cardiopulmonary bypass exceeding 89 min (OR 7.82, 3.25 to 20.42; P < 0.001) as significant independent risk factors for in-hospital death. CONCLUSION Surgical pulmonary embolectomy is rarely performed in the UK, and is associated with significant mortality and morbidity. Preoperative ventilation, cardiogenic shock, and increased duration of bypass were significant predictors of in-hospital death.
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Affiliation(s)
- Amerikos Argyriou
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Hunaid Vohra
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jeremy Chan
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Eltayeb Mohamed Ahmed
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Cha Rajakaruna
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Gianni Davide Angelini
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Daniel Paul Fudulu
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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47
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Horowitz JM, Jaber WA, Stegman B, Rosenberg M, Fanola C, Bhat AP, Gondi S, Castle J, Ahmed M, Brown MA, Amin R, Bisharat M, Butros P, DuCoffe A, Savin M, Pollak JS, Weinberg MD, Brancheau D, Toma C. Mechanical Thrombectomy for High-Risk Pulmonary Embolism: Insights From the US Cohort of the FLASH Registry. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101124. [PMID: 39131977 PMCID: PMC11307390 DOI: 10.1016/j.jscai.2023.101124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2024]
Abstract
Background Acute mortality for high-risk, or massive, pulmonary embolism (PE) is almost 30% even when treated using advanced therapies. This analysis assessed the safety and effectiveness of mechanical thrombectomy (MT) for high-risk PE. Methods The prospective, multicenter FlowTriever All-comer Registry for Patient Safety and Hemodynamics (FLASH) study is designed to evaluate real-world PE patient outcomes after MT with the FlowTriever System (Inari Medical). In this study, acute outcomes through 30 days were evaluated for the subset of patients with high-risk PE as determined by the sites and following European Society of Cardiology guidelines. An independent medical monitor adjudicated adverse events (AEs), including major AEs: device-related mortality, major bleeding, or intraprocedural device-related or procedure-related AEs. Results Of the 799 patients in the US cohort, 63 (7.9%) were diagnosed with high-risk PE; 30 (47.6%) patients showed a systolic blood pressure <90 mm Hg, 29 (46.0%) required vasopressors, and 4 (6.3%) experienced cardiac arrest. The mean age of patients with high-risk PE was 59.4 ± 15.6 years, and 34 (54.0%) were women. At baseline, 45 (72.6%) patients were tachycardic, 18 (54.5%) showed elevated lactate levels of ≥2.5 mM, and 21 (42.9%) demonstrated depressed cardiac index of <2 L/min/m2. Immediately after MT, heart rate improved to 93.5 ± 17.9 bpm. Twenty-five (42.4%) patients did not require an overnight stay in the intensive care unit, and no mortalities or major AEs occurred through 48 hours. Moreover, no mortalities occurred in 61 (96.8%) patients followed up through the 30-day visit. Conclusions In this cohort of 63 patients with high-risk PE, MT was safe and effective, with no acute mortalities reported. Further prospective data are needed in this population.
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Affiliation(s)
- James M. Horowitz
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Brian Stegman
- CentraCare Heart and Vascular Center, St. Cloud, Minnesota
| | - Michael Rosenberg
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Christina Fanola
- Department of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Ambarish P. Bhat
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Missouri, Columbia, Missouri
| | | | - Jordan Castle
- Inland Imaging, Providence Sacred Heart, Spokane, Washington
| | - Mustafa Ahmed
- UAB Division of Cardiovascular Disease, Birmingham, Alabama
| | | | - Rohit Amin
- Ascension Sacred Heart Hospital Pensacola, Pensacola, Florida
| | | | - Paul Butros
- Inova Health System, Fairfax, Virginia
- Southpark Vascular Center, Colonial Heights, Virginia
| | | | - Michael Savin
- Section of Interventional Radiology, Department of Radiology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Jeffrey S. Pollak
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | - Mitchell D. Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | | | - Catalin Toma
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
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48
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Li Y, Li F, Li M, Yi Q, Wu S. Association Between Heart Rate at Diagnosis and Long-Term Recurrence Risk of Pulmonary Embolism in a Historical Cohort Study of Elder Women. Clin Appl Thromb Hemost 2024; 30:10760296241268432. [PMID: 39056293 PMCID: PMC11394350 DOI: 10.1177/10760296241268432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
To investigate the association between heart rate (HR) at diagnosis and long-term pulmonary embolism (PE) recurrence among elderly (≥ 50 year-old) female patients after acute PE (APE). Hospitalized patients with APE were grouped separately according to whether they experienced recurrent PE and whether the HR was < 80 beats/min. Logistic regression and COX regression analysis were employed to assess the risk of PE recurrence. Kaplan-Meier method was applied to compare the recurrence-free survival of PE recurrence. Eighty-five patients were included, including 24 ones with HR < 80 beats/min and 11 recurrent PE cases. The mean time of PE recurrence were 71.7 ± 26.9 months (n = 6) and 27.7 ± 25.2 months (n = 5) among the patients with low HR and with high HR, respectively (P < .001). The HR (< 80 beats/min) was a negative predictor of PE recurrence (OR 0.071 (0.090-0.572), P = .013; HR 0.091 (0.016-0.523), P = .007), even after the adjustment for age, BMI, albumin, risk stratification, surgery, immobility ≥ 4 days, the blood cells counts, bilirubin and complications. The cumulative recurrence-free rates of PE recurrence at the 1st-, 2nd-, 5th-, and 10th-years for the low HR group were 100%, 100%, 87.5%, and 58.3%, compared to the 1st-, 2nd-, and 3rd-years of 94.0%, 93.4%, and 48.0% for the high HR group (log-rank = 0.019). The low HR (< 80 beats/min at diagnosis) among elderly (≥ 50 years old) female patients at APE diagnosis would benefit to the long-term PE recurrence. But limited recurrent cases should be noted.
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Affiliation(s)
- Yuan Li
- Department of Pulmonary and Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Clinical Medical Research Center for Pulmonary and Critical Care Medicine, Changsha, Hunan Province, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
- Hunan Evidence-based Medicine Center, Central South University, Changsha, Hunan, China
| | - Fang Li
- Department of Pulmonary and Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Clinical Medical Research Center for Pulmonary and Critical Care Medicine, Changsha, Hunan Province, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
- Hunan Evidence-based Medicine Center, Central South University, Changsha, Hunan, China
| | - Meizhi Li
- Department of Pulmonary and Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Clinical Medical Research Center for Pulmonary and Critical Care Medicine, Changsha, Hunan Province, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
- Hunan Evidence-based Medicine Center, Central South University, Changsha, Hunan, China
| | - Qiong Yi
- Department of Pulmonary and Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Clinical Medical Research Center for Pulmonary and Critical Care Medicine, Changsha, Hunan Province, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
- Hunan Evidence-based Medicine Center, Central South University, Changsha, Hunan, China
| | - Shangjie Wu
- Department of Pulmonary and Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Clinical Medical Research Center for Pulmonary and Critical Care Medicine, Changsha, Hunan Province, China
- Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan, China
- Hunan Evidence-based Medicine Center, Central South University, Changsha, Hunan, China
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49
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Monteleone P, Ahern R, Banerjee S, Desai KR, Kadian-Dodov D, Webber E, Omidvar S, Troy P, Parikh SA. Modern Treatment of Pulmonary Embolism (USCDT vs MT): Results From a Real-World, Big Data Analysis (REAL-PE). JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101192. [PMID: 39131982 PMCID: PMC11308131 DOI: 10.1016/j.jscai.2023.101192] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 08/13/2024]
Abstract
Background Advanced therapies are increasingly utilized to treat pulmonary embolism (PE). A unique data platform allows access to electronic health record data for comparison of the safety of PE therapies. Methods All data from Truveta (Truveta, Inc) were analyzed (16 systems, 83,612,413 patients, 535,567 with PE). All patients treated with ultrasound-assisted catheter-directed thrombolysis (USCDT) (Boston Scientific) or mechanical thrombectomy (MT) (Inari Medical) for PE were identified. The primary analysis was based on index procedures performed from January 2009 to May 2023, and contemporary analysis on those performed from January 2018 to May 2023. Bleeding was assessed via direct laboratory analysis and transfusion administration documentation. International Society for Thrombosis and Hemostasis (ISTH) and Bleeding Academic Research Consortium (BARC) 3b definitions were recreated. Multiple logistic regression analysis of major bleeding was performed. In-hospital death and median length of stay were measured. Results For the primary analysis, 2259 patients (N = 1577 USCDT, N = 682 MT) and for the contemporary analysis 1798 patients (N = 1137 USCDT, N = 661 MT) met the criteria. Incidence of hemoglobin reduction (>2 and >5 g/dL) and transfusions received were significantly higher among MT-treated patients in both analyses, as was ISTH and BARC 3b major bleeding (primary: ISTH MT 17.3% vs USCDT 12.4% P = .002; BARC 3b MT 15.4% vs USCDT 11.8% P = .019) (contemporary: ISTH MT 17.2% vs USCDT 11.0% P = .0002; BARC 3b MT 15.4% vs USCDT 10.6% P = .002). Regression analysis demonstrated that MT is associated with major bleeding. Median length of stay, all-cause 30-day readmission and in-hospital mortality were similar between groups. Intracranial hemorrhage was more common with MT. Conclusions Major bleeding derived from direct laboratory and transfusion data occurred more frequently with MT vs USCDT. Intracranial hemorrhage was more common among MT-treated patients. In the absence of randomized data, these results provide guidance regarding the bleeding risk and safety of strategies for advanced PE therapy.
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Affiliation(s)
- Peter Monteleone
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas
| | - Ryan Ahern
- Truveta, Inc, Bellevue, Washington
- University of Washington, Seattle, Washington
| | | | - Kush R. Desai
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Patrick Troy
- Hartford Hospital, University of Connecticut School of Medicine, Hartford, Connecticut
| | - Sahil A. Parikh
- Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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50
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Gonsalves CF, Gibson CM, Stortecky S, Alvarez RA, Beam DM, Horowitz JM, Silver MJ, Toma C, Rundback JH, Rosenberg SP, Markovitz CD, Tu T, Jaber WA. Randomized controlled trial of mechanical thrombectomy vs catheter-directed thrombolysis for acute hemodynamically stable pulmonary embolism: Rationale and design of the PEERLESS study. Am Heart J 2023; 266:128-137. [PMID: 37703948 DOI: 10.1016/j.ahj.2023.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND The identification of hemodynamically stable pulmonary embolism (PE) patients who may benefit from advanced treatment beyond anticoagulation is unclear. However, when intervention is deemed necessary by the PE patient's care team, data to select the most advantageous interventional treatment option are lacking. Limiting factors include major bleeding risks with systemic and locally delivered thrombolytics and the overall lack of randomized controlled trial (RCT) data for interventional treatment strategies. Considering the expansion of the pulmonary embolism response team (PERT) model, corresponding rise in interventional treatment, and number of thrombolytic and nonthrombolytic catheter-directed devices coming to market, robust evidence is needed to identify the safest and most effective interventional option for patients. METHODS The PEERLESS study (ClinicalTrials.gov identifier: NCT05111613) is a currently enrolling multinational RCT comparing large-bore mechanical thrombectomy (MT) with the FlowTriever System (Inari Medical, Irvine, CA) vs catheter-directed thrombolysis (CDT). A total of 550 hemodynamically stable PE patients with right ventricular (RV) dysfunction and additional clinical risk factors will undergo 1:1 randomization. Up to 150 additional patients with absolute thrombolytic contraindications may be enrolled into a nonrandomized MT cohort for separate analysis. The primary end point will be assessed at hospital discharge or 7 days post procedure, whichever is sooner, and is a composite of the following clinical outcomes constructed as a hierarchal win ratio: (1) all-cause mortality, (2) intracranial hemorrhage, (3) major bleeding, (4) clinical deterioration and/or escalation to bailout, and (5) intensive care unit admission and length of stay. The first 4 components of the win ratio will be adjudicated by a Clinical Events Committee, and all components will be assessed individually as secondary end points. Other key secondary end points include all-cause mortality and readmission within 30 days of procedure and device- and drug-related serious adverse events through the 30-day visit. IMPLICATIONS PEERLESS is the first RCT to compare 2 different interventional treatment strategies for hemodynamically stable PE and results will inform strategy selection after the physician or PERT determines advanced therapy is warranted.
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Affiliation(s)
| | | | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | | | - Daren M Beam
- Indiana University Health University Hospital, Indianapolis, IN
| | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John H Rundback
- Advanced Interventional & Vascular Services, LLP, Teaneck, NJ
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