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Shatla I, El Iskandarani M, Khan MZ, Elkaryoni A, Elbadawi A, Goel SS, Saad M, Balla S, Darki A, Elgendy IY. Ultrasound-Assisted Versus Standard Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: Insights From National Inpatient Sample. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101360. [PMID: 39132462 PMCID: PMC11308128 DOI: 10.1016/j.jscai.2024.101360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 08/13/2024]
Abstract
Background Pulmonary embolism is one of the leading causes of morbidity and mortality in the United States. Catheter-directed therapies have emerged as a promising treatment for managing intermediate- and high-risk patients; however, data comparing standard catheter-directed thrombolysis (SCDT) and ultrasound-assisted thrombolysis (USAT) are limited. This study aimed to investigate trends, outcomes, and predictors of mortality of both modalities from a nationally representative sample. Methods This analysis used data from the National Inpatient Sample years 2016-2020. The primary outcome was in-hospital mortality. A multivariable regression model was used to compare the outcomes. Results Among 39,430 patients who received catheter-directed thrombolysis, 26,710 (76.8%) received SCDT and 8060 (23.2%) received USAT. The utilization of SCDT and USAT increased during the study years except for 2020. In-hospital mortality was lower among patients who received USAT (2.7% vs 3.8%; P = .04) compared with patients who received SCDT in the unadjusted analysis. On multivariable regression analysis, there was no difference in the incidence of in-hospital mortality between USAT and SCDT (odds ratio, 0.75; 95% CI, 0.52-1.08; P = .13). There were no significant differences between SCDT and USAT groups in the rate of bleeding adverse events including intracranial hemorrhage (0.6% vs 0.4%; P = .47), and nonintracranial major bleeding (4.2% vs 4.1%; P = .72). Conclusions Ultrasound-assisted thrombolysis was associated with similar in-hospital mortality and bleeding complications compared with SCDT for acute pulmonary embolism. Further studies are warranted to confirm evaluate the long-term outcomes with both modalities.
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Affiliation(s)
- Islam Shatla
- Department of Internal Medicine, Kansas University Medical Center, Kansas City, Kansas
| | - Mahmoud El Iskandarani
- Department of Internal Medicine, Eastern Connecticut Health Network, Manchester, Connecticut
| | - Muhammad Zia Khan
- Division of Cardiovascular Disease, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Ahmed Elkaryoni
- Lifespan Cardiovascular Institute and Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ayman Elbadawi
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sachin S. Goel
- Division of Cardiovascular Medicine, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
| | - Marwan Saad
- Lifespan Cardiovascular Institute and Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sudarshan Balla
- Division of Cardiovascular Disease, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Amir Darki
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Islam Y. Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
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Elheet AA, Elhadidy AF, Farrag MH, Mahmoud MA, Ibrahim AA, AlAbdali AM, Kazim H, Elganainy MN. Ultrasound-Facilitated, Catheter-Directed Thrombolysis for Acute Pulmonary Embolism. Cureus 2024; 16:e57345. [PMID: 38690498 PMCID: PMC11060753 DOI: 10.7759/cureus.57345] [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: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Acute pulmonary embolism (APE) poses a significant risk to patient health, with treatment options varying in efficacy and safety. Ultrasound-facilitated catheter-directed thrombolysis (USCDT) has emerged as a potential alternative to conventional catheter-directed thrombolysis (CDT) for patients with intermediate to high-risk APE. This study aimed to compare the efficacy and safety of USCDT versus conventional CDT in patients with intermediate to high-risk APE. METHODS This observational retrospective study was conducted at the Armed Forces Hospital, Al-Hada, Taif, the Kingdom of Saudi Arabia (KSA), on 135 patients diagnosed with APE and treated with either USCDT or CDT (58 underwent CDT, while 77 underwent USCDT). The primary efficacy outcome was the change in the right ventricle to the left ventricle (RV/LV) diameter ratio. Secondary outcomes included changes in pulmonary artery systolic pressure and the Miller angiographic obstruction index score. Safety outcomes focused on major bleeding events. RESULTS Both USCDT and CDT significantly reduced RV/LV diameter ratio (from 1.35 ± 0.14 to 1.05 ± 0.17, P < 0.001) and systolic pulmonary artery pressure (SPAP) (from 55 ± 7 mmHg to 38 ± 7 mmHg, P < 0.001) at 48- and 12-hours post-procedure, respectively, with no significant differences between treatments. However, USCDT was associated with a significantly lower rate of major bleeding events compared to CDT (0% vs. 3.4%, P = 0.008). Multivariate logistic regression analysis revealed that USCDT was associated with a 71.9% risk reduction of bleeding (OR = 0.281, 95% CI = 0.126 - 0.627, P = 0.002). CONCLUSIONS USCDT is a safe and effective alternative to CDT for the treatment of intermediate to high-risk APE, as it significantly reduces the risk of major bleeding.
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Affiliation(s)
- Ahmed A Elheet
- Cardiovascular Disease, Mahalla Cardiac Center, Tanta, EGY
- Cardiovascular Disease, Al Hada Armed Forces Hospital, Taif, SAU
| | | | - Mohamad H Farrag
- Cardiovascular Medicine, Al Hada Armed Force Hospital, Taif, SAU
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Ingemann-Molden S, Caspersen CK, Rolving N, Højen AA, Klok FA, Grove EL, Brocki BC, Andreasen J. Comparison of important factors to patients recovering from pulmonary embolism and items covered in patient-reported outcome measures: A mixed-methods systematic review. Thromb Res 2024; 233:69-81. [PMID: 38029548 DOI: 10.1016/j.thromres.2023.11.013] [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: 07/24/2023] [Revised: 09/25/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Up to 50 % of patients recovering from pulmonary embolism (PE) experience negative long-term outcomes. Patient-reported outcome measures (PROMs) are important in identifying what matters to patients. We aimed to identify PROMs used in clinical studies and recommended by the International Consortium of Health Outcomes (ICHOM) and compare individual items with factors considered important by patients recovering from PE. METHODS This was a convergent mixed-methods systematic review, including quantitative studies, using PROMs and qualitative studies with non-cancer-related PE patients. Items from each PROM and qualitative findings were categorised using an International Classification of Function linking process to allow for integrated synthesis. RESULTS A total of 68 studies using 34 different PROMs with 657 items and 13 qualitative studies with 408 findings were included. A total of 104 individual ICF codes were used, and subsequently sorted into 20 distinct categories representing patient concerns. Identified PROMs were found to adequately cover 17/20 categories, including anxiety, fear of bleeding, stress, depression, dizziness/nausea, sleep disturbance, pain, dyspnea, fatigue, activity levels, family and friends, socializing, outlook on life, and medical treatment. PROMs from the ICHOM core set covered the same categories, except for dizziness/nausea. CONCLUSIONS No single PROM covered all aspects assessed as important by the PE population. PROMs recommended in the ICHOM core set cover 16/20 aspects. However, worrisome thoughts, hypervigilance around symptoms, and uncertainty of illness were experienced by patients with PE but were not covered by PROMS.
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Affiliation(s)
- Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark.
| | | | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark; Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University Hospital and Aalborg University, Aalborg, Denmark
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Haemostasis Leiden University Medical Centre, Leiden, the Netherlands
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University Hospital, Aarhus, Denmark
| | - Barbara Cristina Brocki
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark; Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Aalborg, Denmark
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Snyder DJ, Zilinyi RS, Cohen DJ, Parikh SA, Sethi SS. Patient-Reported Outcomes in Venous Thromboembolism: A Systematic Review of the Literature, Current Challenges, and Ways Forward. J Am Heart Assoc 2023; 12:e032146. [PMID: 38014656 DOI: 10.1161/jaha.123.032146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/04/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) affects >1.2 million Americans annually. Although the clinical outcomes and economic burdens of VTE have been well described, the impact of VTE on patients' health status has yet to be summarized. This systematic review summarizes how patient-reported outcome measures (PROMs) have been used in VTE to date. METHODS AND RESULTS PubMed/MEDLINE was queried for literature published through March 2023 using PROMs in a population of patients with VTE. Studies were excluded if the reference was an editorial, review, or case report, or if the study included patients with conditions other than VTE. Qualitative analyses were performed. After screening and exclusion, 136 references were identified; 5 described PROM development, 20 focused on PROM validation, and 111 used PROMs in outcomes research. The most used generic PROMs were the 36-item Short-Form Health Survey and EuroQol 5-dimensional questionnaire, and the most common disease-specific PROMs were the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms and the Pulmonary Embolism Quality of Life Questionnaire. PROMs were used to quantify the changes in health status after diagnosis, characterize the trajectory of subsequent improvement, and identify drivers of continued impairments in health status like postthrombotic syndrome and postpulmonary embolism syndrome. PROMs were also used to investigate the impact of novel treatment modalities on quality of life. CONCLUSIONS This review demonstrates the many benefits of PROM use, including quantifying changes in health status with treatment, capturing patients' experiences with the treatment itself, and identifying complications of VTE. Incorporating PROMs into VTE care will be an essential component of evaluating the effectiveness of novel therapies and should lead to improved shared decision-making for patients with VTE.
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Affiliation(s)
- Daniel J Snyder
- Department of Medicine, New York Presbyterian Columbia University Irving Medical Center New York NY USA
| | - Robert S Zilinyi
- Division of Cardiology, Department of Medicine Columbia University Irving Medical Center New York NY USA
| | - David J Cohen
- Cardiovascular Research Foundation New York NY USA
- Saint Francis Hospital Roslyn NY USA
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine Columbia University Irving Medical Center New York NY USA
| | - Sanjum S Sethi
- Division of Cardiology, Department of Medicine Columbia University Irving Medical Center New York NY USA
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Farrokhi M, Khurshid M, Yarmohammadi B, Mangouri A, Alipour-Khabir Y, Alipour-Khabir S, Sargazi Moghadam N, Mosalanejad S, Nourizadeh S, Jafari S, Amani-Beni R, Hosseini-Saryazdi SM, Zarei S, Sanjarian S, Babasafari HA, Shakori Poshteh S, Masoudi N, Zahedpasha R, Kiani M, Jalalifar F, Taheri F. Comparison of outcomes and complications in conventional versus ultrasound-accelerated catheter directed thrombolysis for treatment of pulmonary embolism: A systematic review and meta-analysis. Perfusion 2023; 38:1123-1132. [PMID: 35724310 DOI: 10.1177/02676591221108811] [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: 11/15/2022]
Abstract
BACKGROUND Acute submassive a massive pulmonary embolism are known as leading causes of cardiovascular morbidity and mortality in emergency departments. Choosing the optimal type of catheter directed thrombolysis (CDT) for treatment of pulmonary embolism presents a quandary to the practitioners. To the best of our knowledge, there is no meta-analysis comparing superiority of conventional CDT and ultrasound-accelerated catheter directed thrombolysis (USACDT). Therefore, in this meta-analysis, we aimed to compare conventional CDT with USACDT regarding clinical outcomes and safety profile. METHODS A systematic literature search of previous published studies comparing conventional CDT with USACDT regarding clinical outcomes and safety profile was carried out in the electronic databases including MEDLINE, Scopus, EBSCO, Google Scholar, Web of Science, and Cochrane from inception to December 2021. Data were analyzed by comprehensive meta-analysis software (CMA, version 3). RESULTS The meta-analysis included nine studies with a total of 705 patients. Our meta-analysis showed that there is no significant difference between two groups with respect to pulmonary arterial systolic pressure (SMD: -0.084; 95% CI: -0.287 to 0.12; p: 0.41), RV/LV (SMD: -0.003; 95% CI: -0.277 to 0.270; p: 0.98), and Miller score (SMD: -0.345; 95% CI: -1.376 to 0.686; p: 0.51). Similarly, we found no statistically significant differences between two groups regarding major and minor bleeding (p > .05). CONCLUSION Our meta-analysis showed that when compared with USACDT, conventional CDT provides similar clinical and hemodynamic outcomes or safety for treatment of pulmonary embolism without the need for very expensive technologies. However, randomized clinical trials are required to further investigate cost-effectiveness of USACDT in comparison with conventional CDT.
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Affiliation(s)
- Mehrdad Farrokhi
- Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maria Khurshid
- Department of Internal Medicine, Berkshire Medical Center, Pittsfield, MA, USA
| | - Bardia Yarmohammadi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Mangouri
- Department of Vascular and Endovascular Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | | | - Shima Mosalanejad
- Department of Internal Medicine, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Sama Nourizadeh
- School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Sina Jafari
- Faculty of Dentistry, Semnan University of Medical Sciences, Semnan, Iran
| | - Reza Amani-Beni
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Shiva Zarei
- Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sahar Sanjarian
- Lamerd Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hesam-Aldin Babasafari
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | | | - Negar Masoudi
- Department of Nursing, Faculty of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Zahedpasha
- School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Moein Kiani
- School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Fatemeh Jalalifar
- School of Medicine, Jiroft University of Medical Sciences, Jiroft, Iran
| | - Fatemeh Taheri
- Faculty of Pharmacy and Pharmaceutical Sciences, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
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Sistla P, Kheder K, Iourinets J, Arora P, Desai PV, Brailovsky Y, Darki A. Catheter-Directed Thrombolysis or Catheter-Based Thrombectomy in Acute Pulmonary Embolism: Horses for Courses. Interv Cardiol Clin 2023; 12:309-321. [PMID: 37290836 DOI: 10.1016/j.iccl.2023.03.003] [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: 06/10/2023]
Abstract
Venous thromboembolism is a common disorder encompassing both pulmonary embolism (PE) and deep vein thrombosis (DVT). In the United States, up to 2 million people are diagnosed with DVT and 600,000 with PE annually. The purpose of this review is to discuss the indications and evidence for catheter-directed thrombolysis versus catheter-based thrombectomy.
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Affiliation(s)
- Phanicharan Sistla
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Kevin Kheder
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Julia Iourinets
- Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Punit Arora
- Department of Internal Medicine, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Parth V Desai
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Yevgeniy Brailovsky
- Department of Advanced Heart Failure and Transplantation, Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Amir Darki
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA; Cardiology, Loyola University Medical Center, Pulmonary Embolism Response Team.
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7
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Liu H, Wang R, Zhang L, Shi J, Yao J. Clinical Observation of Uninterrupted Thrombolytic Therapy via Indwelling Catheter for Lower Limb Deep Vein Thrombosis. Int J Gen Med 2023; 16:2493-2501. [PMID: 37342406 PMCID: PMC10278963 DOI: 10.2147/ijgm.s416814] [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: 04/12/2023] [Accepted: 06/10/2023] [Indexed: 06/22/2023] Open
Abstract
Purpose Observe uninterrupted thrombolytic therapy via indwelling catheter for lower limb deep vein thrombosis. Methods We retrospectively studied data from 32 patients with lower extremity deep vein thrombosis who received comprehensive treatment, consisting of general treatment, inferior vena cava filter implantation, interventional thrombolysis, angioplasty, stenting, and post-operative monitoring. Results The efficacy and safety of the comprehensive treatment were observed for a follow-up period of 6-12 months. The treatment was 100% effective; patient results indicated no serious bleeding, acute pulmonary embolism, or death after surgery. Conclusion The combination of intravenous and healthy side femoral vein puncture and directed thrombolysis to treat acute lower limb deep vein thrombosis is safe, effective, and minimally invasive while still achieving a good therapeutic effect.
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Affiliation(s)
- Haoyuan Liu
- Department of Intervention, Hexi University Affiliated Zhangye People’s Hospital, Zhangye City, Gansu Province, 734000, People’s Republic of China
| | - Rurong Wang
- Department of Intervention, Hexi University Affiliated Zhangye People’s Hospital, Zhangye City, Gansu Province, 734000, People’s Republic of China
| | - Liang Zhang
- Department of Intervention, Hexi University Affiliated Zhangye People’s Hospital, Zhangye City, Gansu Province, 734000, People’s Republic of China
| | - Jingming Shi
- Department of Intervention, Hexi University Affiliated Zhangye People’s Hospital, Zhangye City, Gansu Province, 734000, People’s Republic of China
| | - Jiaxi Yao
- Institute of Urology, Hexi University, Zhangye City, Gansu Province, 734000, People’s Republic of China
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Carroll BJ, Larnard EA, Pinto DS, Giri J, Secemsky EA. Percutaneous Management of High-Risk Pulmonary Embolism. Circ Cardiovasc Interv 2023; 16:e012166. [PMID: 36744463 DOI: 10.1161/circinterventions.122.012166] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/04/2023] [Indexed: 02/07/2023]
Abstract
Acute pulmonary embolism (PE) leads to an abrupt increase in pulmonary vascular resistance and right ventricular afterload, and when significant enough, can result in hemodynamic instability. High-risk PE is a dire cardiovascular emergency and portends a poor prognosis. Traditional therapeutic options to rapidly reduce thrombus burden like systemic thrombolysis and surgical pulmonary endarterectomy have limitations, both with regards to appropriate candidates and efficacy, and have limited data demonstrating their benefit in high-risk PE. There are growing percutaneous treatment options for acute PE that include both localized thrombolysis and mechanical embolectomy. Data for such therapies with high-risk PE are currently limited. However, given the limitations, there is an opportunity to improve outcomes, with percutaneous treatments options offering new mechanisms for clot reduction with a possible improved safety profile compared with systemic thrombolysis. Additionally, mechanical circulatory support options allow for complementary treatment for patients with persistent instability, allowing for a bridge to more definitive treatment options. As more data develop, a shift toward a percutaneous approach with mechanical circulatory support may become a preferred option for the management of high-risk PE at tertiary care centers.
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Affiliation(s)
- Brett J Carroll
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Emily A Larnard
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Duane S Pinto
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jay Giri
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia (E.A.S.)
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Bruno ES, Mujer MTP, Desai PV, Brailovsky Y, Darki A. A Meta-analysis of Standard Versus Ultrasound-Assisted Catheter-Directed Thrombolysis in the Management of Acute Pulmonary Embolism. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100514. [PMID: 39132529 PMCID: PMC11308803 DOI: 10.1016/j.jscai.2022.100514] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 08/13/2024]
Abstract
Background Standard catheter-directed thrombolysis (SCDT) harnesses the therapeutic benefit of systemic thrombolytics while minimizing bleeding complications in patients presenting with pulmonary embolism (PE). Ultrasound-assisted catheter-directed thrombolysis (USAT) theoretically improves upon SCDT by disrupting fibrin and increasing the surface area exposed to thrombolytic agent. However, it is unclear if this translates into improved outcomes. Methods A systematic search of prior publications comparing SCDT and USAT in patients with intermediate or high-risk PE was conducted. Primary outcomes of interest were bleeding events, ICU and hospital length of stay. Secondary outcomes included changes in pulmonary artery systolic pressure (PASP), mean pulmonary artery pressure (mPAP), and right ventricle to left ventricle diameter (RV/LV) ratio. Studies that lacked comparison groups were excluded. Bias assessments were performed using the Cochrane tools for randomized and nonrandomized studies. Data was collated utilizing the Cochrane Review Manager software, and all analyses assumed random effects. Results Our search yielded 7 observational studies and 1 randomized control trial. The studies included a total of 543 patients who underwent either SCDT (n = 273) or USAT (n = 270) for intermediate or high-risk PE. The synthesized analysis showed no significant differences in bleeding between the groups. There were no differences in ICU or hospital lengths of stay, changes in PASP, or mPAP. Reductions in RV/LV ratio were greater with SCDT (mean difference, -0.16; 95% CI, -0.27 to -0.06; P = .003). Conclusions In comparison to SCDT, USAT did not result in improved clinical or hemodynamic outcomes in patients presenting with PE. Results were limited by heterogeneity among the included studies.
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Affiliation(s)
- Elizabeth S. Bruno
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Mark Terence P. Mujer
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Parth V. Desai
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Yevgeniy Brailovsky
- Division of Cardiology, Department of Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amir Darki
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
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10
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Systemic thrombolytic and ultrasound-assisted catheter-directed thrombolysis for treatment of acute pulmonary embolism: a 7-year, multicenter experience. J Thromb Thrombolysis 2022; 55:545-552. [PMID: 36585600 DOI: 10.1007/s11239-022-02760-z] [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: 12/17/2022] [Indexed: 12/31/2022]
Abstract
Treatment of acute pulmonary embolism (PE) varies based upon risk stratification and ranges from outpatient oral anticoagulation to emergency surgical embolectomy. Patients with high-risk PE can be considered for systemic thrombolytic (ST) based upon guideline recommendations, but intermediate-risk PE does not currently have strong evidence to guide primary reperfusion strategies via thrombolytic administration. Ultrasound-assisted catheter-directed thrombolysis (USAT) is an alternative reperfusion option to ST but is not currently recommended as first line in any key guidelines due to limited available evidence. This retrospective, multicenter, observational study compares 210 patients treated with USAT (n = 105) or ST (n = 105) for acute high- or intermediate-risk PE in three hospitals. Baseline characteristics were significant in that severity of illness was higher in those that received ST, which limited comparisons of outcomes. The primary outcome of major bleeding in patients receiving USAT was 15.2% and 22.9% in those that received ST. Efficacy of reperfusion strategy was observed to be 86.7% of patients in USAT group and 65.7% in ST group. Reperfusion strategies had no difference in in-hospital death, intensive care length of stay, or hospital length of stay. Predefined subgroup analysis found that high-risk PE had higher mortality (14.7%) than intermediate-risk PE (0%) regardless of reperfusion strategy. Upon multivariate analysis, high-risk PE was the only independent risk factor for major bleeding while USAT therapy and intermediate-risk PE were independent predictors of efficacy. Due to the difference in baseline severity of illness, direct comparisons in primary outcomes to each group was not performed. We have described real world usage of both USAT and ST and which patients were likely to receive each therapy at these institutions.
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11
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Sun B, Yang JX, Wang ZK, Zhou HJ, Chu Y, Li Y, Chen RR. Clinical efficacy and safety of ultrasound-assisted thrombolysis vs. standard catheter-directed thrombolysis in patients with acute pulmonary embolism: A study level meta-analysis of clinical trials. Front Cardiovasc Med 2022; 9:967786. [PMID: 36277787 PMCID: PMC9581227 DOI: 10.3389/fcvm.2022.967786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Aim To compare the clinical efficacy of ultrasound-assisted thrombolysis (USAT) vs. standard catheter-directed thrombolysis (SCDT) in patients with acute pulmonary embolism (aPE). Methods This study analyzed the clinical outcomes of patients with non-low-risk aPE who received USAT or SCDT. The primary outcomes were all-cause death, total bleeding, and major bleeding. Secondary outcomes included pulmonary thrombotic load score (Miller), improvement in right ventricular-to-left ventricular ratio (RV/LV), dose and duration of the thrombolytic drug tissue plasminogen activator (tPA), length of stay (LOS) in the ICU, and total LOS in the hospital. Results A total of seven articles and 451 patients were included in this study. 241 patients were in the USAT group and 210 patients were in the SCDT group. There were no significant differences in all-cause mortality, total bleeding, and major bleeding between the two groups. Miller scores for pulmonary thrombus also showed no difference between the two groups, but pulmonary artery systolic pressure (PASP) was lower in the SCDT group after-treatment. The reduction of RV/LV from baseline was more pronounced in the SCDT group than in the USAT group (OR: -0.14, 95%CI: -0.20 to 0.07, P < 0.0001, I 2 = 0%). Total dose of tPA and duration of infusion in the USAT group were lower than those in the SCDT group, but there was no significant statistical difference. LOS in the ICU was similar between the two groups, while LOS in the hospital was lower in the SCDT group. Conclusion This study did not detect any differences in all-cause mortality, total bleeding, and major bleeding between non-low-risk aPE patients treated with USAT or SCDT. Improvement in right ventricular function was better in the SCDT group, and hospital LOS was lower in the SCDT group.
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12
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Carlon TA, Goldman DT, Marinelli BS, Korff RA, Watchmaker JM, Patel RS, Lipson SD, Bishay VL, Lookstein RA. Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy. Radiographics 2022; 42:1861-1880. [PMID: 36190861 DOI: 10.1148/rg.220026] [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: 06/16/2023]
Abstract
Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Timothy A Carlon
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Daryl T Goldman
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Brett S Marinelli
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Ricki A Korff
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Jennifer M Watchmaker
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Rahul S Patel
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Scott D Lipson
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Vivian L Bishay
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Robert A Lookstein
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
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13
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Kroupa J, Buk M, Weichet J, Malikova H, Bartova L, Linkova H, Ionita O, Kozel M, Motovska Z, Kocka V. A pilot randomised trial of catheter-directed thrombolysis or standard anticoagulation for patients with intermediate-high risk acute pulmonary embolism. EUROINTERVENTION 2022; 18:e639-e646. [DOI: 10.4244/eij-d-21-01080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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14
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Lau KK, Steinke K, Reis S, Cherukuri SP, Cejna M. Current trends in image-guided chest interventions. Respirology 2022; 27:581-599. [PMID: 35758539 PMCID: PMC9545252 DOI: 10.1111/resp.14315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/18/2022] [Indexed: 02/06/2023]
Abstract
Interventional radiology (IR) is a rapidly expanding medical subspecialty and refers to a range of image‐guided procedural techniques. The image guidance allows real‐time visualization and precision placement of a needle, catheter, wire and device to deep body structures through small incisions. Advantages include reduced risks, faster recovery and shorter hospital stays, lower costs and less patient discomfort. The range of chest interventional procedures keeps on expanding due to improved imaging facilities, better percutaneous assess devices and advancing ablation and embolization techniques. These advances permit procedures to be undertaken safely, simultaneously and effectively, hence escalating the role of IR in the treatment of chest disorders. This review article aims to cover the latest developments in some image‐guided techniques of the chest, including thermal ablation therapy of lung malignancy, targeted therapy of pulmonary embolism, angioplasty and stenting of mediastinal venous/superior vena cava occlusion, pulmonary arteriovenous malformation treatment and bronchial artery embolization for haemoptysis.
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Affiliation(s)
- Kenneth K Lau
- Monash Imaging, Monash Health, Clayton, Victoria, Australia.,School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin Steinke
- Department of Medical Imaging, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,University of Queensland School of Medicine, St Lucia, Queensland, Australia
| | - Stephen Reis
- Division of Interventional Radiology, Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Srinivas P Cherukuri
- Division of Interventional Radiology, Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Manfred Cejna
- Institute for Diagnostic and Interventional Radiology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
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15
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Kaymaz C, Akbal OY, Keskin B, Tokgoz HC, Hakgor A, Karagoz A, Tanyeri S, Kultursay B, Kulahcioglu S, Dogan C, Bayram Z, Efe SÇ, Erkılınç A, Tanboga IH, Akbulut M, Ozdemir N, Tapson V, Konstantinides S. An Eight-year, Single-center Experience on Ultrasound Assisted Thrombolysis with Moderate-dose, Slow-infusion Regimen in Pulmonary Embolism. Curr Vasc Pharmacol 2022; 20:370-378. [PMID: 36324223 DOI: 10.2174/1570161120666220428095705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/19/2022] [Accepted: 03/10/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is limited data on moderate-dose with slow-infusion thrombolytic regimen by ultrasound-asssisted-thrombolysis (USAT) in patients with acute pulmonary embolism (PE). AIMS In this study, our eight-year experience on USAT with moderate-dose, slow-infusion tissue-type plasminogen activator (t-PA) regimen in patients with PE at intermediate-high- and high-risk was presented, and short-, and long-term effectiveness and safety outcomes were evaluated. METHODS Our study is based on the retrospective evaluation of 225 patients with PE having multiple comorbidities who underwent USAT. RESULTS High- and intermediate-high-risk were noted in 14.7% and in 85.3% of patients, respectively. Mean t-PA dosage was 35.4±13.3 mg, and the infusion duration was 26.6±7.7 h. Measures of pulmonary artery (PA) obstruction and right ventricle (RV) dysfunction were improved within days (p<0.0001 for all). During the hospital stay, major and minor bleeding and mortality rates were 6.2%, 12.4%, and 6.2%, respectively. Bleeding and unresolved PE accounted for 50% and 42.8% of in-hospital mortality, respectively. Age, rate, and duration of t-PA were not associated with in-hospital major bleeding and mortality. Oxygen saturation exceeded 90% in 91.2% of patients at discharge. During follow-up of median 962 (610-1894) days, high-risk status related to 30-day mortality, whereas age >65 years was associated with long-term mortality. CONCLUSION Our real-life experience with USAT with moderate-dose, slow-infusion t-PA regimen in patients with PE at high-and intermediate-high risk demonstrated clinically relevant improvements in PA obstructive burden and RV dysfunction. Age, rate or infusion duration of t-PA was not related to major bleeding or mortality risk, whereas unresolved obstruction remained as a lethal issue.
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Affiliation(s)
- Cihangir Kaymaz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ozgur Yasar Akbal
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Berhan Keskin
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Hacer Ceren Tokgoz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Aykun Hakgor
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ali Karagoz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Seda Tanyeri
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Barkın Kultursay
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Seyhmus Kulahcioglu
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Cem Dogan
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Zubeyde Bayram
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Süleyman Çağan Efe
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Atakan Erkılınç
- Department of Anesthesiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | | | - Mehmet Akbulut
- Faculty of Medicine, Department of Cardiology, Fırat University, Elâzığ, Turkey
| | - Nihal Ozdemir
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Victor Tapson
- Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Stavros Konstantinides
- Department of Cardiology, Democritus University Medical School, Thrace, Greece.,Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Johannes Gutenberg-University, Mainz, Germany
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16
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Ditac G, Bessière F, Lafon C. Therapeutic ultrasound applications in cardiovascular diseases: a review. Ing Rech Biomed 2022. [DOI: 10.1016/j.irbm.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Pietrasik A, Gąsecka A, Szarpak Ł, Pruc M, Kopiec T, Darocha S, Banaszkiewicz M, Niewada M, Grabowski M, Kurzyna M. Catheter-Based Therapies Decrease Mortality in Patients With Intermediate and High-Risk Pulmonary Embolism: Evidence From Meta-Analysis of 65,589 Patients. Front Cardiovasc Med 2022; 9:861307. [PMID: 35783825 PMCID: PMC9243366 DOI: 10.3389/fcvm.2022.861307] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Catheter-directed therapies (CDT) are an alternative to systemic thrombolysis (ST) in pulmonary embolism (PE) patients, but the mortality benefit of CDT is unclear. Objective We conducted a systematic review with meta-analysis to compare the efficacy and safety of CDT and ST in intermediate-high and high-risk PE. Methods We included (P) participants, adult PE patients; (I) intervention, CDT; (C) comparison, ST; (O) outcomes, mortality, complications, in-hospital treatment, and length of hospital stay; (S) study design, randomized controlled trials (RCTs), or cohort comparing CDT and ST. The primary endpoint was 30-day mortality. Secondary outcomes included treatment-related complications including bleeding, the use of hospital resources, and length of hospital stay. Results Eleven studies including 65,589 patients met the inclusion criteria. Thirty-day mortality was lower in the CDT group, compared to ST group [7.3 vs. 13.6%; odds ratio (OR) = 0.51, 95% confidence interval (CI) 0.38–0.69, p < 0.001]. The rates of myocardial injury, cardiac arrest, and stroke were lower in CDT group, compared to ST group (p < 0.001 for all). The rates of any major bleeding, intracranial hemorrhage, hemoptysis, and red blood cell transfusion were lower in patients treated with CDT, compared to ST (p ≤ 0.01 for all). Extracorporeal life support was used more often in patients treated with CDT, compared to ST (0.5 vs. 0.2%, OR = 2.52, 95% CI 1.88–3.39, p < 0.001). The use of hospital resources and length of hospital stay were comparable in both groups. Conclusion CDT might decrease mortality in patients with intermediate-high and high-risk PE and were associated with fewer complications, including major bleeding.
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Affiliation(s)
- Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Arkadiusz Pietrasik,
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Szarpak
- Research Unit, Maria Sklodowska-Curie Białystok Oncology Center, Białystok, Poland
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland
| | - Michał Pruc
- Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland
| | - Tomasz Kopiec
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, Otwock, Poland
| | - Marta Banaszkiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, Otwock, Poland
| | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, Otwock, Poland
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18
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Ultrasound-accelerated thrombolysis in high-risk perioperative pulmonary embolism: two case reports and review of literature. Perioper Med (Lond) 2021; 10:35. [PMID: 34657630 PMCID: PMC8522031 DOI: 10.1186/s13741-021-00205-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 06/26/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Treatment of high-risk pulmonary embolism (PE) in perioperative patients remains challenging. Systemic thrombolysis is associated with a high risk of major bleedings and intracranial haemorrhage. High mortality rates are reported for open pulmonary embolectomy. Therefore, postoperative surgical patients may benefit substantially from catheter-directed ultrasound-accelerated thrombolysis (USAT). Case presentation We report two cases of high-risk perioperative PE. Both patients developed severe haemodynamic instability leading to cardiac arrest. After the implantation of a veno-arterial extracorporeal membrane oxygenation (ECMO), they were both successfully treated with USAT. Adequate improvement of right ventricular function was achieved; thus, ECMO could be successfully weaned after 3 and 4 days, respectively. Both patients showed favourable outcomes and could be discharged to rehabilitation. Conclusion Current guidelines on treatment of PE offer no specific therapies for perioperative patients with high-risk PE. However, systemic thrombolysis is often excluded due to the perioperative setting and the risk of major bleeding. Catheter-directed thrombolysis was shown to utilise less thrombolytic agent while obtaining comparable thrombolytic effects. The risk for major bleeding (including intracranial haemorrhage) is also significantly lowered. Until further trials determining the value of adopted treatment strategies of high-risk PE in perioperative patients are available, USAT should be considered in similar cases.
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19
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Avgerinos ED, Jaber W, Lacomis J, Markel K, McDaniel M, Rivera-Lebron BN, Ross CB, Sechrist J, Toma C, Chaer R. Randomized Trial Comparing Standard Versus Ultrasound-Assisted Thrombolysis for Submassive Pulmonary Embolism: The SUNSET sPE Trial. JACC Cardiovasc Interv 2021; 14:1364-1373. [PMID: 34167677 DOI: 10.1016/j.jcin.2021.04.049] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this trial was to determine whether ultrasound-assisted thrombolysis (USAT) is superior to standard catheter-directed thrombolysis (SCDT) in pulmonary arterial thrombus reduction for patients with submassive pulmonary embolism (sPE). BACKGROUND Catheter-directed therapy has been increasingly used in sPE and massive pulmonary embolism as a decompensation prevention and potentially lifesaving procedure. It is unproved whether USAT is superior to SCDT using traditional multiple-side-hole catheters in the treatment of patients with pulmonary embolism. METHODS Adults with sPE were enrolled. Participants were randomized 1:1 to USAT or SCDT. The primary outcome was 48-hour clearance of pulmonary thrombus assessed by pre- and postprocedural computed tomographic angiography using a refined Miller score. Secondary outcomes included improvement in right ventricular-to-left ventricular ratio, intensive care unit and hospital stay, bleeding, and adverse events up to 90 days. RESULTS Eighty-one patients with acute sPE were randomized and were available for analysis. The mean total dose of alteplase for USAT was 19 ± 7 mg and for SCDT was 18 ± 7 mg (P = 0.53), infused over 14 ± 6 and 14 ± 5 hours, respectively (P = 0.99). In the USAT group, the mean raw pulmonary arterial thrombus score was reduced from 31 ± 4 at baseline to 22 ± 7 (P < 0.001). In the SCDT group, the score was reduced from 33 ± 4 to 23 ± 7 (P < 0.001). There was no significant difference in mean thrombus score reduction between the 2 groups (P = 0.76). The mean reduction in right ventricular/left ventricular ratio from baseline (1.54 ± 0.30 for USAT, 1.69 ± 0.44 for SCDT) to 48 hours was 0.37 ± 0.34 in the USAT group and 0.59 ± 0.42 in the SCDT group (P = 0.01). Major bleeding (1 stroke and 1 vaginal bleed requiring transfusion) occurred in 2 patients, both in the USAT group. CONCLUSIONS In the SUNSET sPE (Standard vs. Ultrasound-Assisted Catheter Thrombolysis for Submassive Pulmonary Embolism) trial, patients undergoing USAT had similar pulmonary arterial thrombus reduction compared with those undergoing SCDT, using comparable mean lytic doses and durations of lysis.
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Affiliation(s)
- Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Joan Lacomis
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kyle Markel
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael McDaniel
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Charles B Ross
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jacob Sechrist
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Rabih Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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20
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Singh M, Shafi I, Rali P, Panaro J, Lakhter V, Bashir R. Contemporary Catheter-Based Treatment Options for Management of Acute Pulmonary Embolism. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:44. [PMID: 33994774 PMCID: PMC8113788 DOI: 10.1007/s11936-021-00920-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 01/21/2023]
Abstract
Introduction Acute pulmonary embolism (PE) remains an important cause of cardiovascular mortality and morbidity in the USA and worldwide. Catheter-based therapies are emerging as a new armamentarium for improving outcomes in these patients. Purpose of review The purpose of this review is to familiarize the clinicians with (1) various types of catheter-based modalities available for patients with acute PE, (2) advantages, disadvantages, and appropriate patient selection for the use of these devices, and (3) evidence base and the relevance of such therapies in the COVID-19 pandemic. Recent findings There are four main types of catheter-based therapies in acute PE: (1) standard catheter-directed thrombolysis (CDT), (2) ultrasound-assisted CDT, (3) pharmacomechanical CDT, and (4) mechanical thrombectomy without thrombolysis. Ultrasound-assisted thrombolysis is the most widely studied modality in this group; however, evidence base for other catheter-based technologies is rapidly emerging. Summary Current use of catheter-based therapies is most suitable for patients with intermediate and high-risk acute PE. The adoption of a multidisciplinary approach like the pulmonary embolism response team (PERT) is desirable for appropriate patient selection and possibly/potentially improving patient outcomes. We discuss the current status of these therapies.
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Affiliation(s)
- Maninder Singh
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA
| | - Irfan Shafi
- Department of Internal Medicine, Wayne State University/DMC, Detroit, MI USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Joseph Panaro
- Department of Radiology, Temple University Hospital, Philadelphia, PA USA
| | - Vladimir Lakhter
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA
| | - Riyaz Bashir
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA.,Division of Cardiovascular Diseases, Temple University Hospital, 3401 N. Broad Street (9PP), Philadelphia, PA 19140 USA
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21
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Knippa S, Vernon S. Evidence-Based Management of a Patient With an EKOS Catheter. Crit Care Nurse 2021; 41:78-80. [PMID: 33791758 DOI: 10.4037/ccn2021182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Sara Knippa
- Sara Knippa is a clinical nurse specialist and clinical nurse educator in the cardiac intensive care unit, University of Colorado Hospital, UCHealth, Aurora, Colorado
| | - Shannon Vernon
- Shannon Vernon is a clinical nurse educator in the surgical trauma intensive care unit at University of Colorado Hospital, and in the intensive care unit at Highlands Ranch Hospital, UCHealth, Highlands Ranch, Colorado
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22
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Allen S, Chan L, Masic D, Porcaro K, Morris S, Haines J, Leya F, Bechara CF, Lopez J, Lewis B, Steen L, Fareed J, Darki A, Brailovsky Y. Comparison of outcomes in catheter-directed versus ultrasound-assisted thrombolysis for management of submassive pulmonary embolism. Thromb Res 2021; 202:96-99. [PMID: 33798805 DOI: 10.1016/j.thromres.2021.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Sorcha Allen
- Department of Cardiovascular Diseases, Loyola University Medical Center, Maywood, IL, United States of America.
| | - Lucas Chan
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, United States of America
| | - Dalila Masic
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, United States of America
| | - Katerina Porcaro
- Department of Cardiovascular Diseases, Loyola University Medical Center, Maywood, IL, United States of America
| | - Stephen Morris
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, United States of America
| | - Jeremiah Haines
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, United States of America
| | - Ferdinand Leya
- Department of Cardiovascular Diseases, Loyola University Medical Center, Maywood, IL, United States of America
| | - Carlos F Bechara
- Department of Vascular Surgery, Loyola University Medical Center, Maywood, IL, United States of America
| | - John Lopez
- Department of Cardiovascular Diseases, Loyola University Medical Center, Maywood, IL, United States of America
| | - Bruce Lewis
- Department of Cardiovascular Diseases, Loyola University Medical Center, Maywood, IL, United States of America
| | - Lowell Steen
- Department of Cardiovascular Diseases, Loyola University Medical Center, Maywood, IL, United States of America
| | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center, Maywood, IL, United States of America
| | - Amir Darki
- Department of Cardiovascular Diseases, Loyola University Medical Center, Maywood, IL, United States of America
| | - Yevgeniy Brailovsky
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
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23
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Clinical outcomes of very elderly patients treated with ultrasound-assisted catheter-directed thrombolysis for pulmonary embolism: a systematic review. J Thromb Thrombolysis 2021; 52:260-271. [PMID: 33665765 DOI: 10.1007/s11239-021-02409-3] [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: 02/16/2021] [Indexed: 10/22/2022]
Abstract
Pulmonary embolism (PE) is a significant cause of death in the very elderly (≥ 75 years) population. Ultrasound-assisted catheter-directed thrombolysis (USCDT) emerges to improve thrombolysis safety and efficacy. However, outcomes in very elderly patients are unknown, as randomized controlled trials exclude this population. Recently, we demonstrated acute kidney injury (AKI) and ischemic hepatitis in an octogenarian intermediate-risk PE patient treated with USCDT. Considering the lack of evidence, we undertook a systematic review to evaluate the clinical outcomes in very elderly PE patients treated with USCDT. We searched for very elderly PE patients treated with USCDT from 2008 to 2019. Additionally, we conducted another systematic review without age restriction to update previous evidence and compare both populations. We also did an exploratory analysis to determine if thrombolysis was followed based on current guidelines or impending clinical deterioration factors. We identified 18 very elderly patients (age 79.2, 75-86), mostly female and with intermediate-risk PE. We found an intracranial hemorrhage (ICH), and a right pulmonary artery rupture. Additionally, two significant bleedings complicated with transient AKI, and one case of AKI and ischemic hepatic injury. The patients who survived all had clinical and echocardiographic in-hospital improvement. Despite low rt-PA doses, ICH and major bleeding remain as feared complications. Thrombolysis decision was driven by impending clinical deterioration factors instead of international guideline recommendations. Our data do not suggest prohibitive risk associated with USCDT in very elderly intermediate and high-risk PE patients. Despite long-term infusions and right ventricular dysfunction, AKI and ischemic hepatic injury were infrequent.
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24
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Todoran TM, Petkovich B. Aggressive Therapy for Acute Pulmonary Embolism: Systemic Thrombolysis and Catheter-Directed Approaches. Semin Respir Crit Care Med 2021; 42:250-262. [PMID: 33548933 DOI: 10.1055/s-0040-1722291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Venous thromboembolism (VTE) is the third most common cause of cardiovascular disease after myocardial infarction and stroke. Population-based studies estimate that up to 94,000 new cases of pulmonary embolism (PE) occur in the United States annually with an increasing incidence with age. Mortality from PE is the greatest in the first 24 hours, with a decreased survival extending out 3 months. Thus, acute PE is a potentially fatal illness if not recognized and treated in a timely manner. Contemporary management includes systemic anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. This article reviews current clinical evidence and societal guidelines for the use of systemic and catheter-directed thrombolysis for treatment of acute PE.
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Affiliation(s)
- Thomas M Todoran
- Division of Cardiovascular Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Bradley Petkovich
- Divisions of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, South Carolina
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25
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Moore K, Kunin J, Alnijoumi M, Nagpal P, Bhat AP. Current Endovascular Treatment Options in Acute Pulmonary Embolism. J Clin Imaging Sci 2021; 11:5. [PMID: 33598362 PMCID: PMC7881502 DOI: 10.25259/jcis_229_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/09/2021] [Indexed: 01/08/2023] Open
Abstract
Acute pulmonary embolism (PE) is a significant cause of mortality and morbidity across the globe. Over the last few decades, there have been major therapeutic advances in acute PE management, including catheter-based therapy. However, the effectiveness of catheter-based therapy in acute PE is not supported by Level I evidence, making the use of this promising treatment rather controversial and ambiguous. In this paper, we discuss the risk stratification of acute PE and review the medical and endovascular treatment options. We also summarize and review the data supporting the use of endovascular treatment options in acute PE and describe the potential role of the PE response team.
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Affiliation(s)
- Kelli Moore
- Department of Radiology, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
| | - Jeff Kunin
- Department of Radiology, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
| | - Mohammed Alnijoumi
- Department of Medicine, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
| | - Prashant Nagpal
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Ambarish P Bhat
- Department of Radiology, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
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26
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Massive Pulmonary Embolism with Cardiac Arrest during Routine Tibial Bypass Surgery. Ann Vasc Surg 2020; 73:509.e15-509.e19. [PMID: 33333184 DOI: 10.1016/j.avsg.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 11/22/2022]
Abstract
We report the case of a massive pulmonary embolism with intraoperative cardiac arrest in a 48-year-old male during routine surgical tibial bypass successfully managed by catheter-based interventions. Our experience supports the trending shift in pulmonary embolism therapy guidelines to include endovascular approaches and emphasizes the need for vascular surgeons to adapt their training protocols.
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27
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Abstract
Purpose of the Review Over 100,000 cardiovascular-related deaths annually are caused by acute pulmonary embolism (PE). While anticoagulation has historically been the foundation for treatment of PE, this review highlights the recent rapid expansion in the interventional strategies for this condition. Recent Findings At the time of diagnosis, appropriate risk stratification helps to accurately identify patients who may be candidates for advanced therapeutic interventions. While systemic thrombolytics (ST) is the mostly commonly utilized intervention for high-risk PE, the risk profile of ST for intermediate-risk PE limits its use. Assessment of an individualized patient risk profile, often via a multidisciplinary pulmonary response team (PERT) model, there are various interventional strategies to consider for PE management. Novel therapeutic options include catheter-directed thrombolysis, catheter-based embolectomy, or mechanical circulatory support for certain high-risk PE patients. Current data has established safety and efficacy for catheter-based treatment of PE based on surrogate outcome measures. However, there is limited long-term data or prospective comparisons between treatment modalities and ST. While PE diagnosis has improved with modern cross-sectional imaging, there is interest in improved diagnostic models for PE that incorporate artificial intelligence and machine learning techniques. Summary In patients with acute pulmonary embolism, after appropriate risk stratification, some intermediate and high-risk patients should be considered for interventional-based treatment for PE.
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28
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Delmas C, Aissaoui N, Meneveau N, Bouvaist H, Rousseau H, Puymirat E, Sapoval M, Flecher E, Meyer G, Sanchez O, Del Giudice C, Roubille F, Bonello L. Reperfusion therapies in pulmonary embolism-state of the art and expert opinion: A position paper from the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology. Arch Cardiovasc Dis 2020; 113:749-759. [PMID: 32978090 DOI: 10.1016/j.acvd.2020.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 01/21/2023]
Abstract
Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Inserm UMR 1048, Institute of Metabolic and Cardiovascular Diseases (I2MC), 31432 Toulouse, France
| | - Nadia Aissaoui
- Critical Care Unit, Penn State Heart and Vascular Institute (HVI), Hershey Medical Center (HMC) and Penn State University, 17033 PA, USA; Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen George Pompidou, AP-HP, 75015 Paris, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, 25000 Besancon, France
| | - Helene Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Hervé Rousseau
- Department of Radiology, Hôpital Rangueil 1, CHU de Toulouse, 31059 Toulouse, France
| | - Etienne Puymirat
- Intensive Cardiac Care Unit, Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Marc Sapoval
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Inserm UMR 1099, 35000 Rennes, France
| | - Guy Meyer
- Department of Pneumology, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris and CIC 1418, 75015 Paris, France
| | - Olivier Sanchez
- Department of Pulmonology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Inserm UMRS 1140, Université de Paris, 75270 Paris, France
| | - Costantino Del Giudice
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - François Roubille
- Department of Cardiology, CHU de Montpellier, Université de Montpellier, Inserm, CNRS, 34295 Montpellier, France
| | - Laurent Bonello
- Intensive Care Unit, Department of Cardiology, Hôpital Nord, AP-HM, Aix-Marseille Université, 13015 Marseille; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13000 Marseille, France; INSERM 1263, 1260, Centre for Cardiovascular and Nutrition Research (C2VN), INRA, 13385 Marseille, France.
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29
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Piazza G, Sterling KM, Tapson VF, Ouriel K, Sharp ASP, Liu PY, Goldhaber SZ. One-Year Echocardiographic, Functional, and Quality of Life Outcomes After Ultrasound-Facilitated Catheter-Based Fibrinolysis for Pulmonary Embolism. Circ Cardiovasc Interv 2020; 13:e009012. [PMID: 32757658 PMCID: PMC7434215 DOI: 10.1161/circinterventions.120.009012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Accelerated tPA (tissue-type plasminogen activator) dosing regimens for ultrasound-facilitated, catheter-directed fibrinolysis improve short-term computed tomographic-measured right ventricular (RV)-to-left ventricular diameter ratio in massive and submassive pulmonary embolism. The impact on RV remodeling, functional status, and quality of life over the long-term remains unclear.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.P.)
| | - Keith M Sterling
- Department of Cardiovascular and Interventional Radiology, INOVA Alexandria Hospital, VA (K.M.S.)
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30
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Adusumalli S, Geller B, Giri J. Catheter-Directed Thrombolysis With Ultrasound Assistance for Acute Pulmonary Embolism: Time to Curb the Enthusiasm? Chest 2020; 157:491-492. [PMID: 32145803 DOI: 10.1016/j.chest.2019.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 10/24/2022] Open
Affiliation(s)
- Srinath Adusumalli
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; The Cardiovascular Quality, Outcomes, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Bram Geller
- Division of Cardiovascular Medicine, Maine Medical Center, Portland, ME
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; The Cardiovascular Quality, Outcomes, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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31
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Beyer SE, Shanafelt C, Pinto DS, Weinstein JL, Aronow HD, Weinberg I, Yeh RW, Secemsky EA, Carroll BJ. Utilization and Outcomes of Thrombolytic Therapy for Acute Pulmonary Embolism. Chest 2020; 157:645-653. [DOI: 10.1016/j.chest.2019.10.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/05/2019] [Accepted: 10/09/2019] [Indexed: 12/16/2022] Open
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32
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Zhang R, Kobayashi T, Pugliese S, Khandhar S, Giri J. Interventional Therapies in Acute Pulmonary Embolism. Interv Cardiol Clin 2020; 9:229-241. [PMID: 32147123 DOI: 10.1016/j.iccl.2019.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Treatment of acute pulmonary embolism (PE) historically included anticoagulation and systemic thrombolytic therapy. More recently, catheter guided interventions provided promise of mitigating bleeding risks usually associated with systemic thrombolysis in intermediate to high risk PE patients. Catheter based interventions can broadly be divided into catheter directed thrombolysis and catheter based embolectomy. Both modalities are currently undergoing active research and each has their respective risks and benefits. The decision to administer these advanced therapies for acute PE can be challenging but can be accomplished via a multi-disciplinary PE response team.
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Affiliation(s)
- Robert Zhang
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Taisei Kobayashi
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Steven Pugliese
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Sameer Khandhar
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Jay Giri
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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33
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Avgerinos ED, Chaer RA, Lacomis J, Lamberty P, McDaniel M, Ocak I, Rivera-Lebron B, Ross C, Sechrist J, Toma C, Wissam J. Standard vs ultrasound-assisted thrombolysis for acute pulmonary embolism: Awaiting the verdict. Vasc Med 2019; 24:547-548. [DOI: 10.1177/1358863x19878492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Heart and Vascular Institute, Presbyterian University Hospital, Pittsburgh, PA, USA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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34
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Khandhar SJ, Mehta M, Cilia L, Palevsky H, Matthai W, Rivera‐Lebron B, Toma C. Invasive hemodynamic assessment of patients with submassive pulmonary embolism. Catheter Cardiovasc Interv 2019; 95:13-18. [DOI: 10.1002/ccd.28491] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/16/2019] [Accepted: 08/22/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Sameer J. Khandhar
- Perelman School of Medicine, Penn‐Presbyterian Medical Center, University of Pennsylvania Philadelphia Pennsylvania
| | - Mili Mehta
- Perelman School of Medicine, Penn‐Presbyterian Medical Center, University of Pennsylvania Philadelphia Pennsylvania
| | - Lindsey Cilia
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Harold Palevsky
- Perelman School of Medicine, Penn‐Presbyterian Medical Center, University of Pennsylvania Philadelphia Pennsylvania
| | - William Matthai
- Perelman School of Medicine, Penn‐Presbyterian Medical Center, University of Pennsylvania Philadelphia Pennsylvania
| | - Belinda Rivera‐Lebron
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh Pennsylvania
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35
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Comparison of Ultrasound-Accelerated Versus Multi-Hole Infusion Catheter-Directed Thrombolysis for the Treatment of Acute Limb Ischemia. Vasc Endovascular Surg 2019; 53:558-562. [DOI: 10.1177/1538574419861768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Thrombolytic therapy is widely used in the treatment of arterial occlusions causing acute limb ischemia (ALI); however, knowledge regarding the efficacy of the different catheter systems available is scarce. The objective of this study was to compare the safety and efficacy of 2 catheter-directed infusion systems for intra-arterial thrombolysis in the setting of ALI. Methods: A retrospective analysis was conducted to study all catheter-directed thrombolysis procedures performed over 32 months in patients diagnosed with ALI. Patients with thrombosis in both native arteries and bypass grafts were included. Patients with contraindications to thrombolysis, or those receiving thrombolysis for deep venous thrombosis, were excluded. The duration of thrombolysis, amount of thrombolytic agent, and technical success rate were recorded. Technical success was defined as complete or near-complete resolution of thrombus burden, allowing for further intervention. Data were stratified to include location of thrombus, procedural complications, mortality, and rates of limb loss. Results: Ninety-one patients met inclusion criteria. Among them, Uni-Fuse and EKOS catheters were used in 69 and 22 patients, respectively. The mean age of the population was 71 (standard deviation [SD]: ±1.5) for patients treated with the EKOS catheter and 70 years (SD: ±2.6) for patients receiving thrombolysis with Uni-Fuse. There was no significant difference in the mean infusion duration (1.65 vs 1.9 days), volume of tissue plasminogen activator (44.6 vs 48.2 mg), or technical success rate (72% vs 86%) between the Uni-Fuse and EKOS cohorts ( P > .3). Furthermore, there was no difference in major limb loss or compartment syndrome between each group ( P > .4). The overall complication rate was 14% in both groups, with a 30-day mortality rate of 4% when treated with either catheter system. Conclusion: This study suggests that a standard multi-hole infusion catheter demonstrates similar clinical safety and efficacy as the ultrasound-accelerated EKOS system in the treatment of ALI.
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36
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Klein AJP, Shishehbor MH. Ultrasound-assisted catheter directed therapy (CDT) for pulmonary embolism versus standard CDT: Sounds of a cry for data! Vasc Med 2019; 24:248-250. [DOI: 10.1177/1358863x19838346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Mehdi H Shishehbor
- CWRU School of Medicine, University Hospitals, Harrington Heart and Vascular Institute, Cleveland, OH, USA
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