Initial experience and early outcomes of the management of acute pulmonary embolism using the FlowTriever mechanical thrombectomy device

Comparison of Safety and Efficacy of Aspiration Thrombectomy and Ultrasound Accelerated Thrombolysis for Management of Pulmonary Embolism: A Systematic Review and Meta-Analysis

PURPOSE

To compare the safety and efficacy of mechanical thrombectomy (MT) and ultrasound-accelerated thrombolysis (USAT) in pulmonary embolism (PE) management by performing a systematic review of the literature.

MATERIALS AND METHODS

The PubMed database was searched to identify articles on Inari's FlowTriever and Penumbra's Indigo mechanical thrombectomy devices (Group A) and the Ekos Endovascular system (Group B). Outcomes variables analyzed include pre- and post-procedure RV/LV ratio, pre- and post-procedure pulmonary artery pressure, hospital length of stay, technical success, specific complications, and mortality rate. Mean values were calculated using the weighted mean approach. RevMan Version 5.4 (Cochrane Collaboration) was used to perform the meta-analysis for this study. Cochrane Collaboration's Risk of Bias (RoB 2.0) approach was used to perform a quality assessment of the included articles in order to verify the validity and reliability of the research.

RESULTS

27 studies were in Group A and 28 studies pertained to Group B. There were 1662 patients in Group A and 1273 patients in Group B. Both groups had similar technical success (99.6% vs 99.4%). Thrombectomy showed longer mean procedure time (73.03 ± 14.57 min vs 47.35 ± 3.15 min), lower mean blood loss (325.20 ± 69.15 mL vs 423.05 ± 64.95 mL), shorter mean ICU stay (2.35 ± 1.64 days vs 3.22 ± 1.27 days), and shorter mean overall hospital stay (6.94 ± 4.38 days vs 7.23 ± 2.31 days). EKOS showed greater mean change in Miller Index (9.05 ± 3.35 vs 4.91 ± 3.70) and greater mean change in pulmonary artery pressure (14.17 ± 6.35 mmHg vs 8.11 ± 4.39 mmHg).

CONCLUSION

Ultrasound accelerated thrombolysis and percutaneous mechanical thrombectomy are effective therapies for pulmonary embolism with comparable clinical outcomes.

Large-bore Aspiration Thrombectomy with the FlowTriever System for the Treatment of Pulmonary Embolism: A Large Single-Center Retrospective Analysis

PURPOSE

Evaluate the outcomes of patients undergoing large-bore aspiration thrombectomy for the treatment of pulmonary embolism at a large university medical center.

MATERIALS AND METHODS

All patients treated for pulmonary embolism with the FlowTriever System (Inari Medical, Irvine, CA) between September 2019 and January 2023 were retrospectively analyzed. The primary safety and effectiveness outcomes included 7- and 30-day all-cause mortality, major bleeding, procedure-associated clinical decompensation, pulmonary vascular or cardiac injury, and pulmonary artery pressure reduction. Additional outcomes included technical success (completing thrombectomy with the device as intended), changes in hemodynamics and supplemental oxygen requirements, and postprocedural intensive care unit stay.

RESULTS

A total of 286 patients were identified. The mean age was 60.5 years, and 90.9% of patients presented with intermediate-risk pulmonary embolism. Technical success was achieved in 96.9% (n = 277) of cases. The average reduction in mean pulmonary arterial pressure was 6.8 mmHg, from 28.7 ± 9.0 to 21.9 ± 8.0 mmHg (p < 0.0001). Two major bleeds (0.7%), 2 pulmonary vascular injuries (0.7%), and 4 (1.4%) procedure-associated decompensations were reported, but no device-related deaths occurred. The mean post-procedure intensive care unit stay was 2.0 ± 4.1 days, and 49.3% of patients had no postprocedural intensive care unit admittance. The overall 7-day and 30-day all-cause mortality rates were 2.4% and 6.7%, respectively, with a 30-day pulmonary embolism-related mortality rate of 3.5%.

CONCLUSION

This non-industry-sponsored single-center analysis of large-bore aspiration thrombectomy in a large population corroborates the findings of other studies and confirms that this approach is safe and effective for the treatment high- and intermediate-risk pulmonary embolism.

LEVEL OF EVIDENCE IV

Retrospective observational study.

Impact of perioperative hemoglobin-related parameters on clinical outcomes in patients with spinal metastases: identifying key markers for blood management

PURPOSE

Patients with spinal metastases undergoing surgical treatment face challenges related to preoperative anemia, intraoperative blood loss, and frailty, emphasizing the significance of perioperative blood management. This retrospective analysis aimed to assess the correlation between hemoglobin-related parameters and outcomes, identifying key markers to aid in blood management.

METHODS

A retrospective review was performed to identify patients who underwent surgical treatment for spinal metastases. Hb-related parameters, including baseline Hb, postoperative nadir Hb, predischarge Hb, postoperative nadir Hb drift, and predischarge Hb drift (both in absolute values and percentages) were subjected to univariate and multivariate analyses. These analyses were conducted in conjunction with other established variables to identify independent markers predicting patient outcomes. The outcomes of interest were postoperative short-term (6-week) mortality, long-term (1-year) mortality, and postoperative 30-day morbidity.

RESULTS

A total of 289 patients were included. Our study demonstrated that predischarge Hb (OR 0.62, 95% CI 0.44-0.88, P = 0.007) was an independent prognostic factor of short-term mortality, while baseline Hb (OR 0.76, 95% CI 0.66-0.88, P < 0.001) was identified as an independent prognostic factor of long-term mortality. Additionally, nadir Hb drift (OR 0.82, 95% CI 0.70-0.97, P = 0.023) was found to be an independent prognostic factor for postoperative 30-day morbidity.

CONCLUSIONS

This study demonstrated that predischarge Hb, baseline Hb, and nadir Hb drift are prognostic factors for outcomes. These findings provide a foundation for precise blood management strategies. It is crucial to consider Hb-related parameters appropriately, and prospective intervention studies addressing these markers should be conducted in the future.

Percutaneous Management of High-Risk Pulmonary Embolism

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.