Role of extracorporeal membrane oxygenation and surgical embolectomy in acute pulmonary embolism

Racial Disparities and Other Socioeconomic Predictors of Mortality in Acute Pulmonary Embolism Treatment from the National Inpatient Sample

PURPOSE

To explore the significance of socioeconomic factors such as race and ethnicity as predictors of mortality in submassive and massive acute pulmonary embolism (PE).

MATERIALS AND METHODS

Hospitalizations of patients aged >18 years with acute, nonseptic PE from 2016 to 2019 were identified from the National Inpatient Sample and divided into interventional radiology (IR) (catheter-directed thrombolysis and thrombectomy) and non-IR (tissue plasminogen activator) treatments. Statistical analyses calculated significant odds ratios (ORs) via 95% confidence intervals (CIs). The primary outcome of interest was mortality rate. Comorbidities affecting mortality were examined secondarily.

RESULTS

Non-Hispanic (NH) Black, Hispanic, and Asian/Pacific Islander patients were significantly less likely to undergo an IR procedure for acute, nonseptic PE compared with White patients (NH Black, OR, 0.83 [95% CI, 0.76-0.90], P < .05; Hispanic, 0.78 [0.68-0.89], P = .06; Asian/Pacific Islander, 0.71 [0.51-0.98], P = .72); however, these differences were eliminated when propensity score matching was performed for age, biological sex, and primary insurance type or for primary insurance type alone. NH Black patients were significantly more likely to die than White patients, regardless of undergoing non-IR or IR treatment. Overall risk of death was 41% higher for NH Black patients than for White patients (relative risk, 1.41 [95% CI, 1.24-1.60]; P < .001).

CONCLUSIONS

NH Black patients have a higher risk of mortality from acute, nonseptic PE than White patients. Independent of race, undergoing IR management for acute, nonseptic PEs was associated with a lower mortality rate. Matching for primary insurance type eliminates differences in mortality between races, suggesting that socioeconomic status may determine outcomes in acute PE.

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

BACKGROUND

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

OBJECTIVE

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

DISCUSSION

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

CONCLUSIONS

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

Surgical pulmonary embolectomy: state of the art

Acute pulmonary embolism is a significant cause of morbidity and mortality. Patients in life-threatening conditions require timely and effective interventions to improve pulmonary perfusion. The indications for surgical embolectomy in the thrombolysis era have been limited. This article discusses surgical techniques and outlines the position of surgical embolectomy concerning other treatment modalities.