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Khazi ZM, Pierce J, Azizaddini S, Davis R, Bhat AP. Mechanical thrombectomy is associated with shorter length of hospital stay and lower readmission rates compared with conservative therapy for acute submassive pulmonary embolism: a propensity-matched analysis. Diagn Interv Radiol 2023; 29:794-799. [PMID: 36994497 PMCID: PMC10679557 DOI: 10.4274/dir.2022.221622] [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: 05/27/2022] [Accepted: 10/30/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE To determine if mechanical thrombectomy (MT) for submassive pulmonary embolism (PE) positively impacts length of hospital stay (LOS), intensive care unit stay (ICU LOS), readmission rate, and in-hospital mortality compared with conservative therapy. METHODS This was a retrospective review of all patients with submassive PE who either underwent MT or conservative therapy (systemic anticoagulation and/or inferior vena cava filter) between November 2019 and October 2021. Pediatric patients (age <18) and those with low-risk and massive PEs were excluded from the study. Patient characteristics, comorbidities, vitals, laboratory values (cardiac biomarkers, hospital course, readmission rates, and in-hospital mortality) were recorded. A 2:1 propensity score match was performed on the conservative and MT cohorts based on age and the PE severity index (PESI) classification. Fischer's exact test, Pearson's χ2 test, and Student's t-tests were used to compare patient demographics, comorbidities, LOS, ICU LOS, readmission rates, and mortality rates, with statistical significance defined as P < 0.05. Additionally, a subgroup analysis based on PESI scores was assessed. RESULTS After matching, 123 patients were analyzed in the study, 41 in the MT cohort and 82 in the conservative therapy cohort. There was no significant difference in patient demographics, comorbidities, or PESI classification between the cohorts, except for increased incidence of obesity in the MT cohort (P = 0.013). Patients in the MT cohort had a significantly shorter LOS compared with the conservative therapy cohort (5.37 ± 3.93 vs. 7.76 ± 9.53 days, P = 0.028). However, ICU LOS was not significantly different between the cohorts (2.34 ± 2.25 vs. 3.33 ± 4.49, P = 0.059). There was no significant difference for in-hospital mortality (7.31% vs. 12.2%, P = 0.411). Of those that were discharged from the hospital, there was significantly lower incidence of 30-day readmission in the MT cohort (5.26% vs. 26.4%, P < 0.001). A subgroup analysis did not demonstrate that the PESI score had a significant impact on LOS, ICU LOS, readmission, or in-hospital mortality rates. CONCLUSION MT for submassive PE can reduce the total LOS and 30-day readmission rates compared with conservative therapy. However, in-hospital mortality and ICU LOS were not significantly different between the two groups.
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Affiliation(s)
- Zain M. Khazi
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Missouri, Missouri, Columbia
| | - Justin Pierce
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Missouri, Missouri, Columbia
| | - Shahrzad Azizaddini
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Missouri, Missouri, Columbia
| | - Ryan Davis
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Missouri, Missouri, Columbia
| | - Ambarish P. Bhat
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Missouri, Missouri, Columbia
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2
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Raza HA, Horowitz J, Yuriditsky E. Indigo ® Aspiration System for thrombectomy in pulmonary embolism. Future Cardiol 2023; 19:469-475. [PMID: 37746827 DOI: 10.2217/fca-2022-0134] [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: 09/26/2023] Open
Abstract
Anticoagulation is mainstay therapy for patients with acute pulmonary embolism while systemic thrombolysis is reserved for those with hemodynamic instability. Over the last decade, percutaneous interventional options have entered the landscape aimed to achieve rapid pharmacomechanical pulmonary artery recanalization. The Penumbra Indigo® Aspiration System (Penumbra Inc., CA, USA) is a US FDA-approved large-bore aspiration thrombectomy device for the treatment of pulmonary embolism. Recent data has demonstrated improved radiographic end points with low rates of major adverse events in cases of intermediate-risk pulmonary embolism. In this review article, we outline device technology, applications, evidence and future directions.
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Affiliation(s)
- Hassan A Raza
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, NYU Langone Health, Mineola, NY 11501, USA
| | - James Horowitz
- Department of Medicine, Division of Cardiology, NYU Langone Health, NY 10016, USA
| | - Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, NYU Langone Health, NY 10016, USA
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3
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Callese TE, Moriarty JM, Maehara C, Cusumano L, Mathevosian S, Enzmann D, Padia SA, Srinivasa RN. Cost drivers in endovascular pulmonary embolism interventions. Clin Radiol 2023; 78:e143-e149. [PMID: 36344283 DOI: 10.1016/j.crad.2022.09.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/17/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
AIM To determine the costs associated with endovascular pulmonary embolism (PE) interventions. MATERIALS AND METHODS Procedural costs were determined utilising time-driven activity-based costing (TDABC). A multidisciplinary team created process maps describing personnel, space, equipment, materials, and time required for each procedural step. Costs and capacity cost rates were determined using institutional and publicly available financial data. RESULTS Process maps were developed for catheter-directed thrombolysis (CDT), ultrasound-assisted thrombolysis (USAT), pharmaco-mechanical thrombectomy (PMT), mechanical-aspiration thrombectomy (MAT), and aspiration thrombectomy (AT). Total costs were CDT $3,889, USAT $9,017.10, PMT $9,565.98, AT $12,126.42, and MAT $13,748.01. Tissue plasminogen activator costs represented 46.4% of the total materials cost for CDT, 13.1% for PMT, and 10.8% for USAT. Intensive care unit costs constitute 33.4% in CDT, 13.5% in USAT, and 13.1% in PMT of the total procedure costs. Highest total procedural costs were AT and MAT with materials cost comprising 82.6% and 80.3% of total costs, respectively. CONCLUSION Costs were greatest with large-bore mechanical aspiration and least with catheter-directed thrombolysis using a multi-side hole infusion catheter. In the absence of a reference standard technique, physician-driven device selection can substantially impact the price of a procedure. Device choice and costs must be weighed against long-term technical and clinical success to maximise the healthcare value equation.
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Affiliation(s)
- T E Callese
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - J M Moriarty
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - C Maehara
- Department of Radiological Sciences, Medical and Imaging Informatics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - L Cusumano
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - S Mathevosian
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - D Enzmann
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - S A Padia
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - R N Srinivasa
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Russo D, Massaro G, Sangiorgi GM. Successful percutaneous catheter-directed treatment of high-risk pulmonary embolism: a case report. AME Case Rep 2023; 7:5. [PMID: 36817704 PMCID: PMC9929660 DOI: 10.21037/acr-22-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023]
Abstract
Background Pulmonary embolism (PE) is an acute cardiovascular syndrome characterized by high incidence and mortality. The therapy of this condition is based on anticoagulation and hemodynamic support, but in case of high-risk mortality, the European Society of Cardiology (ESC) guidelines recommend systemic thrombolytic therapy and surgical embolectomy if thrombolysis is contraindicated or has failed; nowadays several percutaneous catheter-directed treatments for local thrombolysis or mechanical embolectomy are available, but they have IIa class of recommendation, because of lack of robust scientific evidence favoring their use. Case Description We described a case of high-risk PE treated with a novel percutaneous system for mechanical embolectomy, which consists of a large aspiration catheter that was advanced in the pulmonary artery, capturing and removing a vast thrombus, of 15 centimeters in length. This therapeutic strategy avoided the risk of hemorrhagic complications related to systemic thrombolysis, exiting in the achievement of fast patient hemodynamic stabilization and symptoms resolution, without complications. Computed tomography (CT) pulmonary angiography after 10 days from the intervention revealed the complete resolution of pulmonary artery filling defects, and the patient was discharged asymptomatic. Conclusions Percutaneous catheter-directed treatments represent an effective alternative therapy for PE, but further studies are needed to demonstrate safety and superiority over the actually recommended therapy.
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Affiliation(s)
- Debora Russo
- Department of Cardiovascular Disease, University of Rome Tor Vergata, Rome, Italy
| | - Gianluca Massaro
- Department of Cardiovascular Disease, University of Rome Tor Vergata, Rome, Italy
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Serebriakoff P, Cafferkey J, de Wit K, Horner DE, Reed MJ. Pulmonary embolism management in the emergency department: part 2. J Accid Emerg Med 2023; 40:69-75. [PMID: 35383107 DOI: 10.1136/emermed-2021-212001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/20/2022] [Indexed: 01/10/2023]
Abstract
Pulmonary embolism (PE) can present with a range of severity. Prognostic risk stratification is important for efficacious and safe management. This second of two review articles discusses the management of high-, intermediate- and low-risk PE. We discuss strategies to identify patients suitable for urgent outpatient care in addition to identification of patients who would benefit from thrombolysis. We discuss specific subgroups of patients where optimal treatment differs from the usual approach and identify emerging management paradigms exploring new therapies and subgroups.
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Affiliation(s)
| | - John Cafferkey
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Daniel E Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK .,Acute Care Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Endovascular thrombectomy using a stent retriever catheter for massive pulmonary thromboembolism. Am J Emerg Med 2022; 61:233.e3-233.e6. [PMID: 35963656 DOI: 10.1016/j.ajem.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 11/20/2022] Open
Abstract
Acute massive pulmonary thromboembolism (PE) has a high mortality rate of 18%-65%. Along with anticoagulation and thrombolytic therapy, treatment may require a catheter-based thrombectomy or surgical thrombectomy. We report a case of pulmonary thromboembolism treated with a Stent Retriever (Trevo® NXT ProVue Retriever, Stryker, Kalamazoo, MI, USA), which is commonly used to treat stroke. An 81-year-old woman complained of back pain and was transported to our hospital after she became unconscious. Cardiopulmonary resuscitation was initiated before her arrival at the hospital; she returned to spontaneous circulation after arrival. After undergoing computed tomography (CT) scanning, she went into cardiac arrest again, and we established veno-arterial extracorporeal membrane oxygenation and performed catheter thrombectomy using a stent retriever. The left basilar pulmonary artery and the right middle pulmonary artery trunk were retrieved after the stent's deployment, and bilateral pulmonary arteries were confirmed to be reopened. A residual thrombus was present, and Monteplase was administered. A contrast-enhanced CT scan taken on day 15 following admission revealed that the thrombus had disappeared, and echocardiography revealed improved right ventricular dysfunction. The patient was transferred to another hospital on day 64 for rehabilitation. We report the first case of pulmonary artery thrombosis that was successfully recanalized by endovascular treatment with a stent retriever. The stent retriever may be useful as an endovascular treatment device for PE because it is easier to achieve recanalization using this method compared to conventional treatment methods.
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Petrov I, Stankov Z, Dobrev G, Polomski P. COVID-19 infection complicated with acute pulmonary embolism treated with percutaneous pulmonary artery thrombectomy: a case report. Eur Heart J Case Rep 2022; 6:ytac227. [PMID: 35794900 PMCID: PMC9214152 DOI: 10.1093/ehjcr/ytac227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/20/2021] [Accepted: 05/27/2022] [Indexed: 11/15/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) disease is a highly prothrombotic state. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are observed with increased incidence in patients infected with the severe acute respiratory syndrome coronavirus 2 virus. Case summary A 57-year-old male patient with a recent COVID-19 infection complained of leg swelling shortly after his COVID ward discharge. A few days later he was hospitalized with acute massive PE and DVT of his left leg was diagnosed. In another facility, as the first line of treatment, the PE was managed with catheter-directed therapy (CDT) using thrombus defragmentation via 5F (French) Pigtail catheter and supraselective application of 40 mg alteplase. Following the procedure, in addition, 50 mg alteplase was also applied as a 1 hour systemic infusion. Despite the haemodynamic stabilization of the patient, he remained persistently symptomatic and tachycardic. Three days later—in our institution, a second computed tomography pulmoangiography revealed massive thrombotic masses mainly in the left pulmonary artery. Successful percutaneous thrombus aspiration was conducted. The procedure was uneventful with an immediate drop of systolic pulmonary artery pressure from 68 to 47 mmHg and relief of the patient’s symptoms. Discussion In the era of the COVID-19 pandemic, physicians have to remain vigilant of its potential thrombotic complications, the most commonly observed being DVT and PE. We demonstrated the efficacy of percutaneous thrombus aspiration in a patient with acute COVID-19-associated PE, after initial CDT with thrombus defragmentation and high-dose tissue plasminogen activator was implemented with a suboptimal result.
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Affiliation(s)
- Ivo Petrov
- Department of Cardiology and Angiology, Acibadem City Clinic—Cardiovascular Center , Sofia , Bulgaria
| | - Zoran Stankov
- Department of Cardiology and Angiology, Acibadem City Clinic—Cardiovascular Center , Sofia , Bulgaria
| | - Georgi Dobrev
- Department of Cardiology and Angiology, Acibadem City Clinic—Cardiovascular Center , Sofia , Bulgaria
| | - Petar Polomski
- Department of Cardiology and Angiology, Acibadem City Clinic—Cardiovascular Center , Sofia , Bulgaria
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Buckley JR, Wible BC. In-Hospital Mortality and Related Outcomes for Elevated Risk Acute Pulmonary Embolism Treated With Mechanical Thrombectomy Versus Routine Care. J Intensive Care Med 2021; 37:877-882. [PMID: 34397286 DOI: 10.1177/08850666211036446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare in-hospital mortality and other hospitalization related outcomes of elevated risk patients (Pulmonary Embolism Severity Index [PESI] score of 4 or 5, and, European Society of Cardiology [ESC] classification of intermediate-high or high risk) with acute central pulmonary embolism (PE) treated with mechanical thrombectomy (MT) using the Inari FlowTriever device versus those treated with routine care (RC). MATERIALS AND METHODS Retrospective data was collected of all patients with acute, central PE treated at a single institution over 2 concurrent 18-month periods. All collected patients were risk stratified using the PESI and ESC Guidelines. The comparison was made between patients with acute PE with PESI scores of 4 or 5, and, ESC classification of intermediate-high or high risk based on treatment type: MT and RC. The primary endpoint evaluated was in-hospital mortality. Secondary endpoints included intensive care unit (ICU) length of stay, total hospital length of stay, and 30-day readmission. RESULTS Fifty-eight patients met inclusion criteria, 28 in the MT group and 30 in the RC group. Most RC patients were treated with systemic anticoagulation alone (24 of 30). In-hospital mortality was significantly lower for the MT group than for the RC group (3.6% vs 23.3%, P < .05), as was the average ICU length of stay (2.1 ± 1.2 vs 6.1 ± 8.6 days, P < .05). Total hospital length of stay and 30-day readmission rates were similar between MT and RC groups. CONCLUSION Initial retrospective comparison suggests MT can improve in-hospital mortality and decrease ICU length of stay for patients with acute, central PE of elevated risk (PESI 4 or 5, and, ESC intermediate-high or high risk).
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Affiliation(s)
- Jennifer R Buckley
- 24091Saint Luke's Hospital, Kansas City, MO, USA.,12273University of Missouri Kansas City, Kansas City, MO, USA
| | - Brandt C Wible
- 24091Saint Luke's Hospital, Kansas City, MO, USA.,12273University of Missouri Kansas City, Kansas City, MO, USA
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