Catheter-directed Thrombolysis for Intermediate-Risk Pulmonary Embolism

Percutaneous Thrombectomy With Flowtriever System in Pregnant Women With High-Risk Pulmonary Embolism and Contraindications to Systemic Thrombolysis

CLINICAL IMPACT

Through these clinical cases, we present a new protocol of action, updated with the latest evidence on percutaneous pulmonary thrombectomy using dedicated catheters, for high-risk PE in pregnant women or during the early postpartum period.

Relationship between the mixed venous-to-arterial carbon dioxide gradient and the cardiac index in acute pulmonary embolism

AIMS

Among patients with acute pulmonary embolism (PE) undergoing mechanical thrombectomy, the cardiac index (CI) is frequently reduced even among those without a clinically apparent shock. The purpose of this study is to describe the mixed venous-to-arterial carbon dioxide gradient (CO2 gap), a surrogate of perfusion adequacy, among patients with acute PE undergoing mechanical thrombectomy.

METHODS AND RESULTS

This was a single-centre retrospective study of consecutive patients with PE undergoing mechanical thrombectomy and simultaneous pulmonary artery catheterization over a 3-year period. Of 107 patients, 97 had simultaneous mixed venous and arterial blood gas measurements available. The CO2 gap was elevated (>6 mmHg) in 51% of the cohort and in 49% of patients with intermediate-risk PE. A reduced CI (≤2.2 L/min/m2) was associated with an increased odds [odds ratio = 7.9; 95% confidence interval (CI) 3.49-18.1, P < 0.001] for an elevated CO2 gap. There was an inverse relationship between the CI and the CO2 gap. For every 1 L/min/m2 decrease in the CI, the CO2 gap increased by 1.3 mmHg (P = 0.001). Among patients with an elevated baseline CO2 gap >6 mmHg, thrombectomy improved the CO2 gap, CI, and mixed venous oxygen saturation. When the CO2 gap was dichotomized above and below 6, there was no difference in the in-hospital mortality rate (9 vs. 0%; P = 0.10; hazard ratio: 1.24; 95% CI 0.97-1.60; P = 0.085).

CONCLUSION

Among patients with acute PE undergoing mechanical thrombectomy, the CO2 gap is abnormal in nearly 50% of patients and inversely related to the CI. Further studies should examine the relationship between markers of perfusion and outcomes in this population to refine risk stratification.

Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies

Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.

De Ritis Ratio to Predict Clinical Outcomes of Intermediate- and High-Risk Pulmonary Embolisms

Background: Abnormal liver function tests can identify severe cardiopulmonary failure. The aspartate transaminase/alanine transaminase (AST/ALT) ratio, or the De Ritis ratio, is commonly used to evaluate acute liver damage. However, its prognostic value in pulmonary embolism (PE) is unknown. Methods: Two cohorts, including patients with intermediate- and high-risk PEs, were established: one with an abnormal baseline AST/ALT ratio (>1) and another with a normal baseline AST/ALT ratio (<1). The primary outcome was a 60-day mortality. Secondary outcomes included peak N-terminal pro-brain-natriuretic-peptide (NT-proBNP) levels, complications, and the need for critical care treatment. To assess the effect of abnormal AST/ALT ratios, inverse probability weighted (IPW) analyses were performed. Results: In total, 230 patients were included in the analysis, and 52 (23%) had an abnormal AST/ALT ratio. After the IPW correction, patients with an abnormal AST/ALT ratio had a significantly higher mortality rate and peak NT-proBNP levels. The relative risks of 60-day mortality, shock development, use of inotropes/vasopressors, mechanical ventilation, and extracorporeal life support were 9.2 (95% confidence interval: 3.3-25.3), 10.1 (4.3-24), 2.7 (1.4-5.2), 2.3 (1.4-3.7), and 5.7 (1.4-23.1), respectively. Conclusions: The baseline AST/ALT ratio can be a predictor of shock, multiorgan failure, and mortality in patients with a pulmonary embolism.

Palliative Care Penetration Among Hospitalizations with Acute Pulmonary Embolism: A Nationwide Analysis

Background: Integration of palliative care in the management of critical illnesses has been linked with a better quality of life for patients and their families. Yet, there is a paucity of data regarding the role of palliative care for acute pulmonary embolism (PE) hospitalizations which is a leading cause of cardiovascular death in the United States. Methods: Using the Nationwide Inpatient Sample years 2005-2015, acute PE hospitalizations were identified by using ICD-9-codes. The primary outcome was the trends of palliative care penetration during acute PE hospitalizations and the main secondary outcome was the factors associated with palliative care utilization. Results: Among 505,485 acute PE hospitalizations, 15,522 (3.1%) had a palliative care encounter. Hospitalizations with high-risk PE versus non-high-risk PE showed a higher utilization for palliative care (7.6% vs. 2.7%, P < 0.001). The annual trends of palliative care penetration among hospitalizations with PE showed a rising pattern (0.6% in 2005 vs. 5.6% in 2015, Ptrend<0.001). A similar trend was observed among those with high-risk PE (0.8% in 2005 vs. 12.8% in 2015, Ptrend<0.001). The trends of palliative care utilization among cancer and non-cancer admissions increased over time (1.3%in 2005 to 15.5% in 2015 vs. 0.5% in 2005 to 3.9% in 2015, both P-trends<0.001). Some racial and regional disparities were identified among the predictors of palliative care utilization. Conclusions: Palliative care penetration among acute PE hospitalizations remains suboptimal even among high-risk PE, and cancer hospitalizations, but has been increasing in recent years. Future studies are needed to investigate the barriers for palliative care utilization and narrowing this gap among admissions with acute PE.

Trends and outcomes of lytic-based therapies for high-risk pulmonary embolism: A nationwide analysis

BACKGROUND

Systemic thrombolysis (ST) is the guideline-recommended treatment for high-risk pulmonary embolism (PE), although catheter-directed thrombolysis (CDT) may provide a treatment alternative associated with lower rates of bleeding. Furthermore, the treatment trends and outcomes among those with high-risk PE according to treatment assignments of no lytic therapy (NLT), ST, and CDT are underreported.

METHODS

Patients hospitalized for high-risk PE between 2016 and 2019 were identified by administrative claims codes from the National Readmission Database. Therapy assignment was similarly defined by administrative codes, then stratified into NLT, ST, and CDT cohorts to report patient characteristics, care settings, and clinical outcomes. The primary outcome was in-hospital mortality with rates adjusted for patient and hospital characteristics using multivariable logistic regression. Secondary outcomes included intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), and 90-day readmission. Over the years of interest, trends in lytic treatment along with concomitant use of mechanical or surgical thrombectomy were reported.

RESULTS

Among 74,516 patients with high-risk PE, 61,569 (82.6%) received NLT, 8445 (11.3%) received ST, and 4502 (6.04%) received CDT. The NLT subgroup, relative to ST and CDT, tended to be older (66.1 ± 15.4, 62.8 ± 15.3, and 63.4 ± 14.4; p < 0.001) and more frequently women (56.0%, 54.4%, and 51.3%; p < 0.001), respectively. The unadjusted in-hospital mortality rate was highest for ST (18.8%, 34.1%, and 18.3% for NLT, ST, and CDT, respectively; p < 0.001) and persisted after multivariable adjustment (adjusted odds ratio (aOR) 0.43; 95% CI 0.38-0.49; p < 0.0001) of in-hospital mortality for CDT relative to ST. The unadjusted rate of ICH or GIB was lowest for NLT (1.0%, 2.0%, and 0.6% for NLT, ST, and CDT, respectively; p < 0.001). CDT, relative to ST, was associated with reduced odds of ICH (aOR 0.32; 95% CI 0.18-0.55; p < 0.0001) and GIB (aOR 0.78; 95% CI 0.62-0.98; p < 0.0001). Readmissions were highest for NLT (21.7%, 9.6%, and 12.1% for NLT, ST, and CDT, respectively; p < 0.001). CDT was associated with a higher incidence of 90-day readmission relative to ST (aOR 1.32; 95% CI 1.10-1.57; p < 0.001). From 2016 to 2019, individual treatment trends were not significantly different, although NLT tended to be offered among smaller and rural hospitals. Rates of concomitant thrombectomy were low in all three treatment groups.

CONCLUSIONS

Among a large, contemporary, US cohort with high-risk PE, over 80% of patients did not receive any form of thrombolysis. High-risk PE that did receive systemic thrombolysis was associated with the highest rates of in-hospital mortality, suggesting opportunities to study the implementation of lytic and nonlytic-based treatments to improve outcomes for those presenting with high-risk PE.

Special Considerations and Techniques of Interventions in Lung Transplant Recipients

Lung transplant remains an important treatment option for patients with end-stage lung diseases providing improvement in survival rates and quality of life. Specialized considerations should be applied with interventions of lung transplant recipients as they host specific anatomic variations and high risk towards certain complications. In this article, we highlight the role of interventional radiology for lung transplant recipients along with discussion of interventional techniques. Specific emphasis is placed on describing and explaining the techniques pertained to the points of anastomosis, diagnosis and treatment of malignancies, and management of complications in lung transplant recipients.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis

There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.

Cardiovascular collapse during mechanical thrombectomy for acute pulmonary embolism and the role of extracorporeal membrane oxygenation in patient rescue

BACKGROUND

Driven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of intermediate-to-high risk pulmonary embolism (PE). This study investigated the incidence and outcomes of cardiovascular collapse during MT procedures and demonstrates the role of extracorporeal membrane oxygenation (ECMO) in salvaging patients.

METHODS

This single-center retrospective review included patients with PE undergoing MT with the FlowTriever device between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated.

RESULTS

A total of 151 patients with a mean age of 64 ± 14 years who presented with intermediate-to-high risk PE received LBAT procedures during the study period. The simplified PE severity score was ≥1 in 83% of cases and the average RV/LV ratio was 1.6 ± 0.5, with and elevated troponin in 84%. Technical success was achieved in 98.7% and a significant decrease in pulmonary artery systolic pressure (PASP) was observed (37 mm Hg vs 56 mm Hg; P < .0001). Intraoperative cardiac arrest occurred in nine patients (6%). These patients were more likely to present PASP of ≥70 mm Hg (84% vs 14%; P < .001), were more hypotensive upon admission (systolic of 94 ± 14 mm Hg vs 119 ± 23 mm Hg; P = .004), presented lower oxygen saturation levels (87 ± 6% vs 92 ± 6%; P = .023) and were more likely to present with a history of recent surgery (67% vs 18%; P = .004). Four patients were rescued successfully with ECMO and their residual PE was subsequently removed before discharge by surgical embolectomy in two of the four cases and repeat MT in the other two. All five patients (3%) who did not receive ECMO support expired intraoperatively. The overall 30-day mortality was 8% with no death occurring in patients who were salvaged with ECMO.

CONCLUSIONS

Large-bore aspiration thrombectomy for acute PE is associated with favorable technical outcomes, but the concern for acute cardiac decompensation is non-negligible in patients presenting with high-risk features and a PASP of ≥70 mm Hg. ECMO can help to salvage some of these patients and should be considered in the treatment algorithms of patients deemed at high risk.

Right Ventricle Thrombus in the Setting of Submassive Pulmonary Embolism

Submassive pulmonary embolism (PE) with right heart strain and right ventricle thrombus is a complex and potentially life-threatening condition. Prompt recognition and management are crucial to optimizing patient outcomes. We present the case of a 59-year-old male with a history of obstructive sleep apnea (OSA) and non-compliance with continuous positive airway pressure (CPAP) therapy who presented with progressively worsening shortness of breath (SOB). Imaging studies revealed bilateral submassive PE with right heart strain and a thrombus in the right ventricle. Treatment included anticoagulation therapy and mechanical thrombectomy using the INARI FlowTriever device. This case highlights the importance of early recognition and risk factor assessment, such as using testosterone boosters, considering right ventricle thrombus as a complication of PE, and the role of mechanical thrombectomy in selected cases.

Amoeba-Inspired Magnetic Venom Microrobots

Nature provides a successful evolutionary direction for single-celled organisms to solve complex problems and complete survival tasks - pseudopodium. Amoeba, a unicellular protozoan, can produce temporary pseudopods in any direction by controlling the directional flow of protoplasm to perform important life activities such as environmental sensing, motility, predation, and excretion. However, creating robotic systems with pseudopodia to emulate environmental adaptability and tasking capabilities of natural amoeba or amoeboid cells remains challenging. Here, this work presents a strategy that uses alternating magnetic fields to reconfigure magnetic droplet into Amoeba-like microrobot, and the mechanisms of pseudopodia generation and locomotion are analyzed. By simply adjusting the field direction, microrobots switch in monopodia, bipodia, and locomotion modes, performing all pseudopod operations such as active contraction, extension, bending, and amoeboid movement. The pseudopodia endow droplet robots with excellent maneuverability to adapt to environmental variations, including spanning 3D terrains and swimming in bulk liquids. Inspired by the "Venom," the phagocytosis and parasitic behaviors have also been investigated. Parasitic droplets inherit all the capabilities of amoeboid robot, expanding their applicable scenarios such as reagent analysis, microchemical reactions, calculi removal, and drug-mediated thrombolysis. This microrobot may provide fundamental understanding of single-celled livings, and potential applications in biotechnology and biomedicine.

Incidence and Prognostic Role of Pleural Effusion in Patients with Pulmonary Embolism: A Systematic Review and Meta-Analysis

Background: Pleural effusion is a common pulmonary embolism (PE) complication, which has been documented to increase the risk of death in PE and relate to disease progression. However, the incidence of pleural effusion varies among studies and its association with PE outcome is still unclear. This study sought to determine the pooled incidence and prognostic value of pleural effusion events in patients with PE. Methods: We systematically searched the PubMed, EMBASE, SCOPE, Web of Science, Cochrane, LILACS, CINAHL, EBSCO, AMED, and OVID databases from the inception of each database to 7 September 2022 with a restriction on human studies, to identify studies assessing the association between pleural effusion and PE including all prospective and retrospective clinical studies. An exploratory meta-analysis was performed using a random-effects model. We evaluated the heterogeneity and performed subgroup analyses. Results: The final meta-analysis included 29 studies involving 13,430 PE patients. The pooled incidence of pleural effusion in PE patients was 41.2% (95% CI: 35.7–46.6%), which tended to be unilateral (pooled incidence: 60.8%, 95% CI: 45.7–75.8%) and small (pooled incidence: 85.9%, 95% CI: 82.6–89.1%). Pooled analysis using a random-effects model (I2 = 53.2%) showed that pleural effusion was associated with an increased risk of 30-day mortality (RR 2.19, 95% CI: 1.53–3.15, p < 0.001, I2 = 67.1%) and in-hospital mortality (RR 2.39, 95% CI: 1.85–3.09, p < 0.001, I2 = 37.1%) in patients with PE. Conclusions: Our meta-analysis found that PE patients had a high incidence of pleural effusion, which was usually unilateral and small. Pleural effusion generally increases 30-day and in-hospital mortality in patients with PE, and it is recommended that physicians be aware of the risk of death from PE, especially when patients have pleural effusion. Further investigations focusing on PE with pleural effusion are warranted.

Unplanned 30-Day Readmissions after Management of Submassive and Massive Acute Pulmonary Embolism: Catheter-Directed versus Systemic Thrombolysis

PURPOSE

To compare 30-day readmission and in-hospital outcomes from the Nationwide Readmissions Database (NRD) for catheter-directed thrombolysis (CDT) versus systemic intravenous thrombolysis (IVT) as treatments for acute submassive or massive pulmonary embolism (PE).

MATERIALS AND METHODS

The NRD was queried from 2016 to 2019 for adult patients with nonseptic acute PE who underwent IVT or CDT. Massive PE was distinguished from submassive PE if patients had concurrent International Classification of Diseases (ICD-10) codes corresponding to mechanical ventilation, vasopressors, or shock. Propensity score-matched analysis was conducted to infer the association of CDT versus IVT in unplanned 30-day readmissions, nonroutine discharge, gastrointestinal bleeding (GIB), and intracranial hemorrhage (ICH). These results are demonstrated as average treatment effects (ATEs) of IVT compared with those of CDT.

RESULTS

A total of 37,116 patients with acute PE were studied; 18,702 (50.3%) underwent CDT, and 18,414 (49.7%) underwent IVT. A total of 2,083 (11.1%) and 3,423 (18.6%) were massive PEs in the 2 groups, respectively (P < .001). The ATE of IVT was higher than that of CDT regarding unplanned 30-day readmissions (ATE, 0.019; P < .001), GIB (ATE, 0.012; P < .001), ICH (ATE, 0.003; P = .017), and nonroutine discharge (ATE, 0.022; P = .006). The subgroup analysis of patients with submassive PE demonstrated that IVT had a higher ATE regarding unplanned 30-day readmission (ATE, 0.028; P < .001), GIB (ATE, 0.008; P = .003), ICH (ATE, 0.002; P = .035), and nonroutine discharge (ATE, 0.019; P = .022) than CDT.

CONCLUSIONS

CDT had a lower likelihood of unplanned 30-day readmissions, including when stratified by a submassive PE subtype. Additionally, adverse events, including ICH and GIB, were more likely among patients who received IVT than among those who received CDT.

A Synergistic and Efficient Thrombolytic Nanoplatform: A Mechanical Method of Blasting Combined with Thrombolytic Drugs

BACKGROUND AND OBJECTIVE

Thrombosis is a common disease that poses a great threat to life and health. Most thrombolytic effects of traditional treatments or nanomedicine are not efficient or safe enough. Therefore, we designed a nanoparticle (NP) with a combination of a phase transition material and thrombolytic drugs for efficient and safe thrombolysis.

METHODS

A thrombus fibrin-targeted and phase transition NP was designed and contained perfluorohexane (PFH) and the thrombolytic drug rtPA core, with CREKA polypeptides attached to the shell of the PLGA NPs. Characterization of the phase transition and ultrasound imaging of the NPs was carried out under low-intensity focused ultrasound (LIFU). LIFU-responsive drug release in vitro was also explored. Under the synergistic effect of PFH and rtPA, the efficient thrombolysis ability of the NPs was studied in vitro and in vivo. In vivo monitoring of thrombosis and biosafety were also verified.

RESULTS

The PPrC NPs had good ultrasound imaging ability under LIFU irradiation and were related to the phase transition characteristics of the NPs. CREKA polypeptides can effectively increase the aggregation of the NPs on thrombi. Under static and dynamic conditions in vitro, the "liquid to gas" transformation effect of PFH can perform the destruction function of the excavator at the thrombus site and promote the specific release of rtPA, and the subsequent rtPA drug thrombolysis can further fully dissolve the thrombus. In vivo experiments showed that the NPs can monitor the formation of thrombi and have good thrombolytic effects, with significantly reduced bleeding side effects. The biochemical indexes of the rats were within normal limits after treatment.

CONCLUSION

PPrC NPs loaded with PFH and rtPA combining a mechanical way of blasting with thrombolytic drugs may be a promising new and reliable approach for thrombus monitoring and treatment.

Utilization trends and outcomes of catheter-directed thrombolysis for pulmonary embolism in the US by race/ethnicity

Contemporary data on catheter-directed thrombolysis (CDT) utilization trends and associated hospital outcomes in pulmonary embolism (PE) n the US is limited. Using the nationwide inpatient sample database, we identified patients hospitalized for acute PE treated with CDT from January 1, 2008, to December 31, 2018. Cochrane-Armitage test was used to evaluate the temporal trends in utilization, hospital mortality, and major bleeding rates. Multivariate logistic regression was used to compare differences in the outcomes across race/ethnicity, 4444 patients (unweighted hospitalizations) underwent CDT during the study period. The mean age ± standard deviation of the population was 58 ± 16 years and the majority were males (54%). 3269 (73.6%) patients were non-Hispanic White (NHW), 802 (18.0%) patients were non-Hispanic Black (NHB), and 373 (8.4%) patients were of 'other' races/ethnicities. There was a more than tenfold increase in CDT use in 2018 compared to 2008. The total mortality and bleeding rates were approximately 7 and 10% respectively. Hospital mortality rates trended down across all races/ethnicities during the study period. A similar downward trend in bleeding rates was noted in NHB only (28.6% vs 10.7%, p = 0.04). In-hospital mortality and major bleeding odds were comparable across all races/ethnicities were comparable. NHB patients and other races were more likely to require blood transfusion and incur higher hospitalization costs compared with NHW patients. CDT use increased significantly in the US during the study period with a corresponding downward trend in in-hospital mortality across all races, and bleeding rates in NHB.

How we dealt with the double whammy! Acute pulmonary embolism with abdominal aortic clot and renal infarcts

Pulmonary embolism (PE) is the third most common cause of cardiovascular mortality in the United States, and the submassive PE accounts for 20%-25% of all acute PE. In the last decade, endovascular therapy with catheter-directed thrombolysis (CDT) intervention has shown great success in the treatment of submassive PE. There is limited data regarding using these devices to treat patients with concomitant abdominal aortic and renal vessel clots. Herein, we present a case of a 23-year-old male who presented with submassive PE associated with abdominal aortic thrombosis and renal infarcts. The patient was successfully treated with CDT with complete resolution of pulmonary and bilateral renal artery clots.

Impact of pulmonary embolism response teams on acute pulmonary embolism: a systematic review and meta-analysis

BACKGROUND

The impact of pulmonary embolism response teams (PERTs) on treatment choice and outcomes of patients with acute pulmonary embolism (PE) is still uncertain.

OBJECTIVE

To determine the effect of PERTs in the management and outcomes of patients with PE.

METHODS

PubMed, Embase, Web of Science, CINAHL, WorldWideScience and MedRxiv were searched for original articles reporting PERT patient outcomes from 2009. Data were analysed using a random effects model.

RESULTS

16 studies comprising 3827 PERT patients and 3967 controls met inclusion criteria. The PERT group had more patients with intermediate and high-risk PE (66.2%) compared to the control group (48.5%). Meta-analysis demonstrated an increased risk of catheter-directed interventions, systemic thrombolysis and surgical embolectomy (odds ratio (OR) 2.10, 95% confidence interval (CI) 1.74-2.53; p<0.01), similar bleeding complications (OR 1.10, 95% CI 0.88-1.37) and decreased utilisation of inferior vena cava (IVC) filters (OR 0.71, 95% CI 0.58-0.88; p<0.01) in the PERT group. Furthermore, there was a nonsignificant trend towards decreased mortality (OR 0.87, 95% CI 0.71-1.07; p=0.19) with PERTs.

CONCLUSIONS

The PERT group showed an increased use of advanced therapies and a decreased utilisation of IVC filters. This was not associated with increased bleeding. Despite comprising more severe PE patients, there was a trend towards lower mortality in the PERT group.

Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management

Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.

EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer

In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.

Thrombus Distribution in Vaccine-induced Immune Thrombotic Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination

This case series reports 40 patients (median age, 41 years [interquartile range (IQR) 32- 52, 22 men) with confirmed vaccine-induced immune thrombotic thrombocytopaenia after administration of their first ChAdOx1 nCov-19 (AstraZeneca) vaccine: 80% (n=32) developed symptoms within the first 14 days and 20% (n=8) within 14-28 days. The location and extent of thrombi were evaluated using CT, MRI and ultrasound. Of the 40, 73% (n=29) presented with neurological symptoms and had confirmed cerebral venous sinus thrombosis, 30% (n=12) had extension of their primary thrombus, and 20% (n=8) died. 83% of those who underwent additional imaging (25 of 30) had occult thrombosis.

Case Report: Pericardial Tamponade and Hemothorax After Superior Vena Cava Filter Removal

A 67-year-old male patient was admitted to receive surgical treatment because of lumbar spinal stenosis. Ultrasonography showed a thrombus in the middle and lower segment of the left internal jugular vein. Superior vena cava filter implantation was performed and removed on day 7 after its implantation. The patient suddenly had dyspnea, and his blood pressure decreased 9 h after filter removal. Examinations showed pericardial tamponade and hemothorax. In addition, aortic dissection occurred approximately 20 days after superior vena cava filter removal. This case aimed to provide information to clinicians about the complications of the implantation and removal of superior vena cava filter implantation. The safety and possible complications of superior vena cava filter implantation and removal should be evaluated to identify their actual clinical benefit and cost-effectiveness ratio.

Subclavian Effort Thrombosis: Pathophysiology, Diagnosis, and Management

Subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome or venous thoracic outlet syndrome, is an uncommon condition that affects individuals with an irregularly narrow thoracic outlet who engage in repetitive overhead motions of the affected arm. Venous injury arises from microtraumas that occur from the repetitive compression of the SCV between the first rib and the overlying clavicle. Additional sources of extrinsic compression can be due to the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. SCV effort thrombosis is a distinct entity from other forms of deep venous thrombosis and requires unique diagnostic and treatment considerations. Early catheter-directed therapy in the form of pharmacomechanical or catheter-directed thrombolysis combined with prompt surgical thoracic outlet decompression offers patients the best chances for early and durable symptom relief.

Pharmacological and interventional management of pulmonary embolism: where do we stand?

As the third most common cardiovascular disease, pulmonary embolism (PE) has an uptrending incidence and mortality, resulting in significant healthcare expenditure. Risk stratification of acute PE guides management. Although anticoagulation remains the cornerstone management, systemic fibrinolysis and targeted therapeutic approaches, catheter-directed thrombolysis and catheter-based embolectomy are available for high-risk patients. Life-threatening bleeding complications associated with systemic fibrinolysis have restricted its widespread implementation. Catheter-based techniques for intermediate high-risk categories were devised to reduce bleeding complications and improve outcomes. Catheter-directed thrombolysis helps minimize bleeding by way of direct drug delivery. Catheter-based embolectomy mechanically retrieves thrombi without using fibrinolytics. This focused review of medical and interventional management of acute PE provides a highlight of ongoing trials expected to add value to current practice.

Catheter-directed thrombolysis in a COVID-19 patient complicated with pulmonary embolism

Since December 2019, the novel coronavirus (COVID-19) outbreak has become an important public health problem and one of the most common causes of morbidity and mortality worldwide. COVID-19 is highly associated with thromboembolic events, like deep venous thrombosis and pulmonary embolism (PE). Catheter-directed thrombolysis (CDT) provides effective reperfusion for the treatment of PE. We report a patient who was presented with intermediate-risk PE and had a saccular aneurysm of the anterior cerebral artery. The patient was suffered from recent COVID-19 infection and ischemic stroke. As the patient had high bleeding risk for full-dose systemic thrombolytic therapy, CDT was the preferred method for reperfusion. Finally, the patient was discharged from the hospital uneventfully 4 days later. In the setting of high bleeding risk, CDT seems to be an effective and safe approach in patients with intermediate-risk PE.

An Untapped Resource: Characteristics of Thrombus Recovered from Intermediate or High Risk Pulmonary Embolus Patients

INTRODUCTION

Response to anticoagulation varies during management of acute hospitalized pulmonary embolism. We aimed to study thrombus histology in pulmonary embolism samples removed during acute surgical embolectomy to evaluate whether thrombus morphology was similar between patients and whether there was an association with duration of symptoms and/or resolution on follow up imaging.

METHODS

This was a retrospective observational single center study at the University of Rochester Medical Center. We evaluated patients that underwent acute surgical embolectomy and followed up in our clinic 2-4 months after the event with Ventilation/Perfusion (V/Q) scan obtained for all regardless of symptoms. Thromboemboli were formalin fixed and processed for light microscopy in the hospital histopathology laboratory. Four-micron thick sections were stained with hematoxylin and eosin, Masson trichrome, and Verhoeff elastic tissue stains. Immunohistochemistry was performed using anti-CD31 and anti-CD68. Slides were independently evaluated for time-dependent microscopic changes using Irniger's classification by two blinded pathologists.

RESULTS

Sixteen patients underwent embolectomy with fifteen having V/Q imaging at follow up. The majority of patients were female. Samples showed a generally similar overall architecture that included a central core composed primarily of red blood cells and fibrin and an outer layer of platelets and monocytes. Two samples had evidence of fibrosis and recanalization.

CONCLUSIONS

We found heterogeneous histopathology in samples obtained during acute embolectomy. Further prospective studies should systematically characterize clot morphology and evaluate treatment response and outcomes. Careful thrombus specimen measurement and consistent sampling for sections will be required to draw firm conclusions.

Repeat angiography in patients undergoing conventional catheter-directed thrombolysis for submassive pulmonary embolism: a large single-center experience

PURPOSE

Few studies have examined conventional catheter directed thrombolysis (CDT) for the treatment of submassive pulmonary embolism (PE). Moreover, angiographic resolution of thrombus burden following CDT has infrequently been characterized. This study describes a single-center experience treating submassive PE with CDT while utilizing repeat angiography to determine treatment efficacy.

METHODS

A retrospective analysis of 140 consecutive patients who underwent CDT for submassive PE from December 2012 to June 2019 was performed. Angiographic resolution of thrombus burden after CDT was reported as high (>75%), moderate (51-75%), low (26-50%), or insignificant (≤25%). All angiograms were reviewed by two interventional radiologists. Secondary endpoints included reduction in pulmonary artery pressure (PAP) and clinical outcomes. Bleeding events were classified according to the Society of Interventional Radiology (SIR) adverse event criteria.

RESULTS

CDT was performed in 140 patients with a mean rtPA dose of 25.3 mg and a mean treatment time of 26.0 hours. Angiographic resolution of thrombus burden was high in 70.0%, moderate in 19.3%, low in 5.7%, and insignificant in 3.6%; in 2 patients (1.4%) repeat angiography was not performed. Systolic PAP was reduced (47 vs. 35 mmHg, p < 0.001), mean PAP was reduced (25 vs 21 mmHg, p < 0.001), and 129 patients (92.1%) improved clinically. Patients with high or moderate resolution of thrombus burden had a clinical improvement rate of 95.2%, while patients with low or insignificant thrombus burden resolution had a clinical improvement rate of 76.9% (p=0.011). Ten patients (7.1%) had hemodynamic or respiratory decompensation requiring mechanical ventilation, systemic thrombolysis, cardiopulmonary resuscitation, or surgical intervention. Seven patients (5.0%) experienced moderate bleeding events and one patient (0.7%) with metastatic disease developed severe gastrointestinal bleeding that resulted in death. Thirty-day mortality was 1.4%.

CONCLUSION

In patients with submassive PE undergoing CDT, angiographic resolution of thrombus burden is a safe and directly observable metric that can be used to determine procedural success. In this study, CDT with repeat angiography was associated with a 5.7% bleeding event rate and thirty-day mortality of 1.4%.

Predictors of residual pulmonary vascular obstruction after anticoagulation monotherapy in patients with intermediate-risk pulmonary embolism

Background

Patients with intermediate-risk pulmonary embolism (PE) can be treated with anticoagulation monotherapy. However, clinicians are concerned as to whether anticoagulation monotherapy is sufficient to reduce mortality in patients with a large embolic burden, and to resolve vascular obstruction. We investigated whether anticoagulation monotherapy was appropriate in patients with intermediate risk PE in terms of the occurrence of residual pulmonary vascular obstruction (RPVO), and the factors that independently predict the occurrence of RPVO.

Methods

This was a multicenter retrospective observational study of patients at intermediate risk of PE who were admitted to three hospitals between January 2012 and December 2017.

Results

Of total 91 patients, the median age was 72 years and 37 (40.7%) were male. Twenty-five patients (27.5%) were diagnosed with RPVO during follow-up. Multivariate logistic regression revealed chronic lung disease [odds ratio (OR), 4.14; 95% confidence interval (CI), 1.243–13.797; P=0.021] and the ratio of the diameters of the main pulmonary artery and ascending aorta ratio (P/A ratio) >1.0 documented on a chest computed tomography (CT) at presentation (OR, 3.46; 95% CI, 1.113–10.770; P=0.032) were significant independent predictors of RPVO occurrence. The incidence of RPVO in patients without these two factors was only 9.7%, but in those with the two factors it was 60% (P=0.004).

Conclusions

Anticoagulation monotherapy did not seem to be a sufficient treatment to reduce RPVO, but the outcome was similar to that of patients treated with other therapies. Therefore, considering the risk-benefit ratio, we do not need to change the initial treatment as systemic thrombolytic therapy or catheter-based therapy in patient with intermediate risk PE. Underlying chronic lung disease and a P/A ratio >1 on the initial chest CT predicted the occurrence of RPVO. Therefore, we should carefully assess persistent of dyspnea and exercise limitations using various methods in patients with these risk factors, to detect the occurrence of chronic thromboembolic pulmonary disease (CTEPD) earlier.

Resting heart rate as a surrogate for improvement in intermediate risk pulmonary embolus patients?

BACKGROUND

Pulmonary embolism (PE) response teams (PERT) have been developed to improve in-hospital mortality. Identifying intermediate risk PE patients that will progress despite anticoagulation is difficult, especially because outcomes with modern anticoagulation are quite good.

OBJECTIVE

The primary aim of this study was to evaluate the rate of anticoagulation failure (new deep vein thrombosis or PE, right ventricular failure resulting in shock, cardiac arrest, or PE-attributable death) in intermediate risk PE patients managed by PERT. The secondary objective was to determine whether there was a significant decrease in heart rate 24 h after initiation of anticoagulation in intermediate risk PE.

METHODS

This was a retrospective observational study of patients treated for acute intermediate risk PE at the University of Rochester Medical Center who also had outpatient followup between November 2016-June 2019.

RESULTS

Ninety-two patients presented as intermediate-risk PE and had outpatient followup. Seventy-four patients were initially treated with anticoagulation. None of these patients failed anticoagulation. Of the eighteen intermediate risk patients that underwent advanced intervention, none failed anticoagulation first. There was significant decrease in resting heart rate 24 h after starting therapeutic anticoagulation, 107 beats/min vs 89 beats/min, p = 0.0001.

CONCLUSION

We did not observe anticoagulation failure in the management of acute, intermediate risk PE. Reductions in heart rate may reflect improvements in right ventricular function; we hypothesize that those whose heart rate does not fall may be optimal candidates for advanced intervention.

Safety and efficacy of catheter-directed therapy versus anticoagulation alone in a higher-risk acute pulmonary embolism population

There is little data comparing safety and efficacy outcomes in patients with pulmonary embolism (PE) receiving catheter directed therapies (CDT) compared to a similar-risk cohort of PE patients receiving anticoagulation alone. 1094 patients with acute PE were studied. CDT and conservatively-managed patients were compared using propensity score matching to assess safety outcomes, which included bleeding and acute kidney injury at 2 and 7 days after PE diagnosis. Efficacy outcomes included change in vital signs over 72 h and in-hospital mortality. PE patients with RV strain who underwent CDT (n = 76) had more bleeding at 2 days (additional 1.04 g/dL loss, 95% CI − 1.48 to − 0.60, p < 0.001) and 7 days (additional 1.36 g/dL loss, 95% CI − 1.88 to − 0.84, p < 0.001) compared to those receiving anticoagulation alone (n = 303). There was a significant increase in creatinine at 2 days (additional 0.22 mg/dL elevation, 95% CI 0.02 to 0.42, p = 0.03), but not at 7 days (additional 0.12 mg/dL elevation, 95% CI − 0.11 to 0.35, p = 0.30). In-hospital mortality for patients receiving CDT versus anticoagulation alone was similar (OR 1.21, 95% CI 0.53 to 2.77; p = 0.65). In patients with baseline abnormal vital signs who received CDT versus anticoagulation alone, heart rate, respiratory rate and oxygen requirement improved significantly faster and to levels closer to normal (p ≤ 0.001). CDT was associated with a small but increased risk of bleeding, but no significant worsening of renal function. CDT may be associated with more rapid improvements in heart rate, respiratory rate, and oxygen requirement.

A Case of Failure of EkoSonic™ Endovascular System in the Treatment of Submassive Pulmonary Embolism

Submassive pulmonary embolism (SPE) is characterized by the presence of right ventricular (RV) strain as visualized on echocardiogram or CT scan with brain natriuretic peptide (BNP) and/or troponin elevation. The condition accounts for 20-25% of all pulmonary embolism (PE) cases. In cases of SPE, catheter-directed thrombolysis (CDT) is generally considered in the presence of severe hypoxemia, worsening RV dysfunction, patients with increasing tachycardia and elevated troponins, free-floating thrombus in the right atrium or RV, and presence of extensive clot burden. EkoSonic™ Endovascular System (EKOS; Boston Scientific, Marlborough, MA) has been successfully used to treat cases of PE even where systemic thrombolytic therapy has failed. However, in this article, we describe a unique case of the failure of EKOS in treating a 71-year-old African American man who presented to the hospital with progressively worsening chest pain, shortness of breath, and fatigue. He was suspected to have SPE; however, a CT pulmonary angiogram could not be performed to estimate the clot burden due to an acute kidney injury. He was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia during the hospitalization and had a delayed EKOS procedure with minimal improvement in oxygenation and clot burden. He subsequently underwent half-dose systemic thrombolytic therapy with complete resolution of his symptoms. Given our success with half-dose systemic therapy, we propose that it may be considered as a "rescue therapy" in cases where EKOS fails to deliver results.

Midterm Prognosis of Patients With Pulmonary Embolism Receiving Catheter-Directed Thrombolysis or Systemic Thrombolysis: A Nationwide Population-Based Study

Background This study compared the efficacy and safety between catheter-directed thrombolysis (CDT) and systemic thrombolysis for patients with acute pulmonary embolism (PE) with midterm follow-up. Methods and Results We conducted a prospective open cohort study by using data from the Taiwan National Health Insurance Research Database for 2001 to 2013. Patients who were first admitted for PE and were treated by either systemic thrombolysis or CDT were included and compared. Inverse probability of treatment weighting, based on the propensity score, was used to mitigate possible selection bias. A total of 145 CDT-treated and 1158 systemic thrombolysis-treated patients with PE were included. The in-hospital mortality rate was significantly lower in the CDT group (12.7% versus 21.4%; odds ratio, 0.49; 95% CI, 0.36-0.67) after inverse probability of treatment weighting. No significant differences between the groups were observed for the safety (bleeding) outcomes. In patients who survived the index PE admission, the 1-year all-cause mortality rate was significantly lower in the CDT group after inverse probability of treatment weighting (12.2% versus 13.2%; hazard ratio [HR], 0.73; 95% CI, 0.56-0.94). Treatment with CDT was also associated with lower risks of recurrent PE (9.3% versus 17.5%; subdistribution HR, 0.52; 95% CI, 0.41-0.66). The difference remained through the last follow-up. Conclusions Among patients with PE requiring reperfusion therapy, those accepting CDT had lower all-cause mortality and recurrent PE over both short-term and midterm follow-up periods than those receiving systemic thrombolysis. The bleeding risk was similar for both groups. These findings should be cautiously validated in future randomized trials.

Management of Acute Pulmonary Embolism in a Patient with Sickle Cell Anemia Using Catheter-Directed Thrombolysis

The efficacy of thrombolytic therapy in submassive pulmonary embolism (PE) management is lacking, particularly in specific patient subgroups. The current case report demonstrates the use of catheter-directed thrombolysis (CDT) therapy in conjunction with standard systemic anticoagulation in a patient with sickle cell disease presenting with a submassive PE and chronic thrombus burden. CDT may potentially play a role in the management of submassive PE in sickle cell patients.

Meta-Analysis of the Usefulness of Inferior Vena Cava Filters in Massive and Submassive Pulmonary Embolism

To conduct a systematic review and meta-analysis evaluating the safety and effectiveness of inferior vena cava filter (IVCF) placement in the setting of massive and submassive pulmonary embolism (PE), Pubmed and Cochrane Library were queried to identify all clinical studies evaluating IVCF placement in patients with massive and submassive PE from database establishment to December 2019. The rate of recurrent PE, PE-related mortality, adverse events, IVCF type, additional treatment intervention, DVT status, and follow-up length were retrieved. Recurrent PE, mortality, and complication rates were pooled. Meta-analysis was performed to compare mortality rates between groups with and without IVCF placement. Subgroup analysis was performed based on whether catheter-directed therapy was used for PE intervention. Fifteen observational studies with a total of 232 patients who received IVCF for submassive or massive PE were included. The pooled overall recurrent symptomatic PE and mortality rates were 1.4% and 5.5%, respectively. A lower mortality rate among patients with IVCF was observed than those without (6.8% vs 26.3%; odds ratio [OR] 0.275 [95% confidence interval] 0.090 to 0.839], I² = 30.6%, p = 0.023). Patients who received concurrent catheter-directed therapy demonstrated a lower recurrent PE (0% vs 2.8%) and mortality rate (3.4% vs 7.8%) than those who did not. The cumulative IVCF-related complication rate was 0.63%. In conclusion, based on a limited amount of low-quality evidence, IVCF placement is associated with low recurrent PE and PE-related mortality rates among patients with massive and submassive PE, suggestive of a potential clinical benefit in this scenario. Prospectively designed studies are warranted to confirm these findings.

Effects of Changes in ICU Bed Supply on ICU Utilization

BACKGROUND

The availability of intensive care unit (ICU) beds may influence the demand for critical care. Although small studies support a model of supply-induced demand in the ICU, there is a paucity of system-wide data.

OBJECTIVE

The objective of this study was to determine the relationship between ICU bed supply and ICU admission in United States hospitals.

RESEARCH DESIGN

Retrospective cohort study using all-payer inpatient records from Florida, Massachusetts, New Jersey, New York, and Washington from 2010 to 2012, linked to hospital data from Medicare's Healthcare Cost Reporting Information System.

SUBJECTS

Three patient groups with a low likelihood of benefiting from ICU admission-low severity patients with acute myocardial infarction and pulmonary embolism; and high severity patients with metastatic cancer at the end of life.

MEASURES

We compared the risk-adjusted probability of ICU admission at hospitals that increased their ICU bed supply over time to matched hospitals that did not, using a difference-in-differences approach.

RESULTS

For patients with acute myocardial infarction, ICU supply increases were associated with an increase in the probability of ICU admission that diminished over time. For patients with pulmonary embolism, there was a trend toward an association between change in ICU supply and ICU admission that did not meet statistical significance. For patients with metastatic cancer, admission to hospitals with an increasing ICU supply was not associated with changes in the probability of ICU admission.

CONCLUSIONS

Increases in ICU bed supply were associated with inconsistent changes in the probability of ICU admission that varied across patient subgroups.

Local Pro- and Anti-Coagulation Therapy in the Plastic Surgical Patient: A Literature Review of the Evidence and Clinical Applications

The risks of systemic anti-coagulation or its reversal are well known but accepted as necessary under certain circumstances. However, particularly in the plastic surgical patient, systemic alteration to hemostasis is often unnecessary when local therapy could provide the needed adjustments. The aim of this review was to provide a summarized overview of the clinical applications of topical anti- and pro-coagulant therapy in plastic and reconstructive surgery. While not a robust field as of yet, local tranexamic acid (TXA) has shown promise in achieving hemostasis under various circumstances, hemostats are widely used to halt bleeding, and local anticoagulants such as heparin can improve flap survival. The main challenge to the advancement of local therapy is drug delivery. However, with increasingly promising innovations underway, the field will hopefully expand to the betterment of patient care.

Preservation of Cardiopulmonary Function in Patients Treated with Ultrasound-Accelerated Thrombolysis in the Setting of Submassive Pulmonary Embolism

PURPOSE

To evaluate the clinical effectiveness of ultrasound-assisted thrombolysis (USAT) in resolution of right ventricular dysfunction (RVD), preservation of cardiopulmonary function, and quality of life (QoL) in patients with acute submassive pulmonary embolism (PE).

MATERIALS AND METHODS

A single-center prospective study of patients presenting with acute PE and signs of RVD, as determined by right ventricle-to-left ventricle diameter ratio (RV:LV) > 0.9 on computed tomographic angiography of the thorax, was performed. Patients underwent USAT with recombinant tissue plasminogen activator. Primary endpoints measured were RV:LV by echocardiogram at baseline presentation and at 72 hours and 90 days after treatment. Secondary endpoints were QoL scores assessed by SF-36 Health Surveys at baseline and at 90 days, cardiopulmonary exercise test (CPET) parameters at 90 days, and procedural outcomes, including response of pulmonary artery pressure (PAP) and procedural complications.

RESULTS

Twenty-five patients were treated between June 17, 2013, and September 15, 2014, with mean reduction of RV:LV by echocardiogram from 1.38 ± 0.28 at presentation to 0.92 ± 0.14 (P < .0001) at 72 hours and 0.84 ± 0.25 (P < .0001) at 90 days. SF-36 Health Survey scores demonstrated no long-term self-perceived adverse physical or mental effects as a result of PE. CPET parameters, including VO2_max, weight-adjusted VO2, VE/VCO2, and VD/VT demonstrated no pulmonary vascular impairment at 90 days. PAP significantly improved after USAT, with mean initial systolic pressure of 50.46 ± 13.98 mmHg reduced to 39.64 ± 8.66 mmHg (P = .0001). There were no deaths, recurrent venous thromboembolism, hemodynamic decompensation, or hemorrhage.

CONCLUSIONS

USAT resulted in significant reduction of RV:LV at 72 hours, which was preserved at 90 days. QoL and objective measures of cardiopulmonary function are preserved at 90 days in this population. Further studies with long-term follow-up are needed to determine the potential value of USAT for the prevention of post-PE syndrome in patients with submassive PE.