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Yu A, Birkemeier KL, Mills JR, Kuo T, Tachikawa N, Dai F, Thakkar K, Cable C, Brenner A, Godley PJ. Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management. Cardiol Ther 2024; 13:541-556. [PMID: 38773006 PMCID: PMC11333655 DOI: 10.1007/s40119-024-00370-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). METHODS A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. RESULTS Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. CONCLUSION Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.
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Affiliation(s)
- Anthony Yu
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | | | - J Rebecca Mills
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Tiffany Kuo
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Nina Tachikawa
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Feng Dai
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Karishma Thakkar
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Christian Cable
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Allison Brenner
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Paul J Godley
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA.
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Baron SJ, Gibson CM, Gandhi RT, Mittleider D, Dexter D, Jaber WA. Trends in Percutaneous Device Use for the Treatment of Venous Thromboembolism Over Time in the PINC AI Healthcare Database and the National Inpatient Sample. Am J Cardiol 2024; 222:167-174. [PMID: 38641190 DOI: 10.1016/j.amjcard.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/19/2024] [Accepted: 04/13/2024] [Indexed: 04/21/2024]
Abstract
The number of different methods of reperfusion therapy to treat venous thromboembolism (VTE) has increased substantially. Nevertheless, investigation of data representativeness and device-level use in administrative databases has been limited. Using the National Inpatient Sample (NIS) and the PINC AI Healthcare Database (PHD), all hospital encounters with a diagnosis code of VTE were identified between January 1, 2016 and December 31, 2020. Patient demographics and trends in treatment modalities were evaluated over time. An algorithm was developed to identify specific devices used for VTE treatment in the PHD cohort. A total of 145,870 patients with VTE treated with reperfusion therapy were identified in the NIS (pulmonary embolism [PE] 88,725, isolated deep vein thrombosis [iDVT] 57,145) and 39,311 in the PHD (PE 25,383, iDVT 13,928). Patient demographics were qualitatively similar in the NIS and PHD. Over time, there was a significant increase in the use of mechanical thrombectomy in the PE and iDVT populations (p <0.05 in both databases), with catheter-directed thrombolysis use plateauing in PE (p = 0.83 and p = 0.14 in NIS and PHD, respectively) and significantly decreasing for the iDVT population (p <0.05 in both databases). In the PHD cohort, specific reperfusion devices were identified in 14,105 patients (PE 9,098, iDVT 5,007). In conclusion, the use of mechanical thrombectomy for the treatment of VTE has increased over time, whereas the rates of catheter-directed thrombolysis therapy have remained stagnant or decreased. Further research is needed to understand the uptake of these treatment modalities and the unique abilities of the PHD to study specific device therapy in the VTE population.
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Affiliation(s)
- Suzanne J Baron
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Baim Institute for Clinical Research, Boston, Massachusetts.
| | - C Michael Gibson
- Baim Institute for Clinical Research, Boston, Massachusetts; Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Wissam A Jaber
- Department of Medicine, Emory University, Atlanta, Georgia
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Mohr K, Keeling B, Kaier K, Neusius T, Rosovsky RP, Moriarty JM, Rosenfield K, Abele C, Farmakis IT, Keller K, Barco S, Channick RN, Giri JS, Lookstein RA, Todoran TM, Christodoulou KC, Hobohm L, Lanno M, Reed J, Binder H, Konstantinides SV, Valerio L, Secemsky EA. Modelling costs of interventional pulmonary embolism treatment: implications of US trends for a European healthcare system. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:501-505. [PMID: 38349225 PMCID: PMC11214584 DOI: 10.1093/ehjacc/zuae019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 07/01/2024]
Abstract
AIMS Catheter-directed treatment (CDT) of acute pulmonary embolism (PE) is entering a growth phase in Europe following a steady increase in the USA in the past decade, but the potential economic impact on European healthcare systems remains unknown. METHODS AND RESULTS We built two statistical models for the monthly trend of proportion of CDT among patients with severe (intermediate- or high-risk) PE in the USA. The conservative model was based on admission data from the National Inpatient Sample (NIS) 2016-20 and the model reflecting increasing access to advanced treatment from the PERT™ national quality assurance database registry 2018-21. By applying these models to the forecast of annual PE-related hospitalizations in Germany, we calculated the annual number of severe PE cases and the expected increase in CDT use for the period 2025-30. The NIS-based model yielded a slow increase, reaching 3.1% (95% confidence interval 3.0-3.2%) among all hospitalizations with PE in 2030; in the PERT-based model, increase would be steeper, reaching 8.7% (8.3-9.2%). Based on current reimbursement rates, we estimated an increase of annual costs for PE-related hospitalizations in Germany ranging from 15.3 to 49.8 million euros by 2030. This calculation does not account for potential cost savings, including those from reduced length of hospital stay. CONCLUSION Our approach and results, which may be adapted to other European healthcare systems, provide a benchmark for healthcare costs expected to result from CDT. Data from ongoing trials on clinical benefits and cost savings are needed to determine cost-effectiveness and inform reimbursement decisions.
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Affiliation(s)
- Katharina Mohr
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Brent Keeling
- Division of Cardiothoracic Surgery, Emory University Hospital, Atlanta, GA, USA
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Thomas Neusius
- Wiesbaden Business School, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Rachel P Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John M Moriarty
- Division of Interventional Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Christina Abele
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
- School of Life Sciences, University of Siegen, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Richard N Channick
- Pulmonary and Critical Care Division, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jay S Giri
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Lookstein
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas M Todoran
- Medical University of South Carolina, Charleston, SC, USA
- Cardiovascular Division, Department of Medicine, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Konstantinos C Christodoulou
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | | | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, University General Hospital, Dragana, 68100 Alexandroupolis, Greece
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Giri J, Mahfoud F, Gebauer B, Andersen A, Friedman O, Gandhi RT, Jaber WA, Pereira K, West FM. PEERLESS II: A Randomized Controlled Trial of Large-Bore Thrombectomy Versus Anticoagulation in Intermediate-Risk Pulmonary Embolism. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101982. [PMID: 39132600 PMCID: PMC11308785 DOI: 10.1016/j.jscai.2024.101982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 08/13/2024]
Abstract
Background Anticoagulation (AC) is the guideline-recommended treatment for intermediate-risk pulmonary embolism (PE); however, it remains unclear whether mechanical thrombectomy provides benefit over AC alone. The PEERLESS II study aims to evaluate outcomes in intermediate-risk PE patients randomized to treatment with large-bore mechanical thrombectomy and AC vs AC alone. Methods PEERLESS II is an international randomized controlled trial enrolling up to 1200 patients with intermediate-risk PE and additional clinical risk factors from up to 100 sites. Treatment is randomized 1:1 to large-bore mechanical thrombectomy with the FlowTriever System (Inari Medical) and AC or AC alone. Outcomes will be evaluated for up to 3 months, with safety events independently adjudicated. The primary end point is a hierarchical composite win ratio of (1) all-cause mortality by 30 days, (2) clinical deterioration (earlier of discharge or 30 days), (3) all-cause hospital readmission by 30 days, (4) bailout therapy (earlier of discharge or 30 days), and (5) Modified Medical Research Council (mMRC) dyspnea score of ≥1 at the 48-hour visit. Secondary end points include all-cause and PE-related mortality (30-day and 90-day), all-cause and PE-related readmission (30-day and 90-day), major bleeding (30-day and 90-day), clinical deterioration (earlier of discharge or 30 days), bailout (earlier of discharge or 30 days), right ventricle-to-left ventricle diameter ratio (48-hour visit), mMRC dyspnea score (48-hour, 1-month, and 3-month visits), quality of life using Pulmonary Embolism Quality of Life and EuroQol-5 Dimensions-5 Levels (1-month and 3-month visits), 6-minute walk distance (1-month visit), and post-PE impairment diagnosis (3-month visit). Conclusions PEERLESS II will inform the understanding of mechanical thrombectomy treatment for intermediate-risk PE and provide evidence for consideration in future treatment guidelines.
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Affiliation(s)
- Jay Giri
- Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Felix Mahfoud
- Department of Cardiology, Saarland University Hospital, Homburg, Germany
| | - Bernhard Gebauer
- Department of Radiology, Charité University Hospital, Berlin, Germany
| | - Asger Andersen
- Department of Cardiological Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Oren Friedman
- Department of Internal Medicine, Cedars-Sinai, Los Angeles, California
| | - Ripal T. Gandhi
- Department of Radiology, Miami Cardiac and Vascular Institute, Miami, Florida
| | | | - Keith Pereira
- Department of Radiology, St. Louis University, St. Louis, Missouri
| | - Frances M. West
- Division of Pulmonary and Critical Care Medicine, Jefferson Health, Philadelphia, Pennsylvania
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Mohr K, Hobohm L, Kaier K, Farmakis IT, Valerio L, Barco S, Abele C, Münzel T, Neusius T, Konstantinides S, Binder H, Keller K. Drivers and recent trends of hospitalisation costs related to acute pulmonary embolism. Clin Res Cardiol 2024:10.1007/s00392-024-02437-y. [PMID: 38565711 DOI: 10.1007/s00392-024-02437-y] [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] [Received: 01/11/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIMS The socio-economic burden imposed by acute pulmonary embolism (PE) on European healthcare systems is largely unknown. We sought to determine temporal trends and identify cost drivers of hospitalisation for PE in Germany. METHODS AND RESULTS We analysed the totality of reimbursed hospitalisation costs in Germany (G-DRG system) in the years 2016-2020. Overall, 484 884 PE hospitalisations were coded in this period. Direct hospital costs amounted to a median of 3572 (IQR, 2804 to 5869) euros, resulting in average total reimbursements of 710 million euros annually. Age, PE severity, comorbidities and in-hospital (particularly bleeding) complications were identified by multivariable logistic regression as significant cost drivers. Use of catheter-directed therapy (CDT) constantly increased (annual change in the absolute proportion of hospitalisations with CDT + 0.40% [95% CI + 0.32% to + 0.47%]; P < 0.001), and it more than doubled in the group of patients with severe PE (28% of the entire population) over time. Although CDT use was overall associated with increased hospitalisation costs, this association was no longer present (adjusted OR 1.02 [0.80-1.31]) in patients with severe PE and shock; this was related, at least in part, to a reduction in the median length of hospital stay (for 14.0 to 8.0 days). CONCLUSIONS We identified current and emerging cost drivers of hospitalisation for PE, focusing on severe disease and intermediate/high risk of an adverse early outcome. The present study may inform reimbursement decisions by policymakers and help to guide future health economic analysis of advanced treatment options for patients with PE.
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Affiliation(s)
- Katharina Mohr
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Christina Abele
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Thomas Neusius
- Wiesbaden Business School, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Gandhi RT, Gibson CM, Jaber WA. A cross-sectional study of outcomes for patients undergoing mechanical thrombectomy for pulmonary embolism during 2018-2022: Insights from the PINC AI Healthcare Database. Health Sci Rep 2024; 7:e2031. [PMID: 38650733 PMCID: PMC11033482 DOI: 10.1002/hsr2.2031] [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] [Received: 09/26/2023] [Revised: 02/15/2024] [Accepted: 03/13/2024] [Indexed: 04/25/2024] Open
Abstract
Background and Aims Mechanical thrombectomy (MT) treatments for pulmonary embolism (PE) have yet to be compared directly. We aimed to determine if patient outcomes varied following treatment of PE with different MT devices. Methods All PE encounters with an index treatment of MT between January 2018 and March 2022 were analyzed for in-hospital mortality, discharge to home, and 30-day readmission outcomes in the PINC AI™ Healthcare Database. MT devices used in each encounter were extracted from hospital charge description free-text fields using keyword text and fuzzy matching. Unadjusted and adjusted logistic regression was used to model outcomes by device. Results A total of 5893 encounters were identified using MT as the sole index PE treatment and 1812 using MT with another treatment. Of these, 41% had insufficient information to identify the devices used (unspecified MT), 33% used the FlowTriever System (large-bore volume-controlled aspiration MT), 23% the Indigo System (continuous aspiration MT), and 3% some other MT. Large-bore volume-controlled aspiration MT was used with other treatments 13% of the time compared with 23% and 39% for unspecified MT and continuous aspiration MT, respectively. Adjusted logistic regression modeling revealed the odds of in-hospital mortality were significantly higher for patients treated with unspecified MT ([OR] = 1.42, 95% confidence interval [CI]: [1.10-1.83], p = 0.008) or continuous aspiration MT (OR = 1.63, 95% CI: [1.21-2.19], p = 0.001) compared with large-bore volume-controlled aspiration MT. Discharge to home was significantly lower in these same groups (OR = 0.84, 95% CI: [0.73-0.96], p = 0.01, and OR = 0.63, 95% CI: [0.53-0.74], p < 0.001, respectively), but readmission risks at 30 days were comparable (OR = 1.08, 95% CI: [0.84-1.38], p = 0.56, and OR = 1.20, 95% CI: [0.89-1.62], p = 0.24, respectively). Conclusion PE outcomes and treatment patterns differ significantly based on the type of MT utilized. Clinical studies directly comparing MT treatments are needed to further understand optimal treatment of PE.
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Affiliation(s)
| | - C. Michael Gibson
- Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Wissam A. Jaber
- Division of Cardivascular MedicineEmory University School of MedicineAtlantaGeorgiaUSA
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Rastogi R, Okunowo O, Faerber JA, Mavroudis CD, Whitworth H, Giglia TM, Witmer C, Raffini LJ, O'Byrne ML. Incidence, Management, and Outcomes of Pulmonary Embolism at Tertiary Pediatric Hospitals in the United States. JACC. ADVANCES 2024; 3:100895. [PMID: 38939674 PMCID: PMC11198360 DOI: 10.1016/j.jacadv.2024.100895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/18/2023] [Accepted: 01/02/2024] [Indexed: 06/29/2024]
Abstract
Background Pediatric pulmonary embolism (PE) is rare and potentially life-threatening. Though thrombolysis and thrombectomy are increasingly used in adult PE, trends in pediatric treatment and outcomes remain incompletely described. Objectives The purpose of this study was to describe the incidence of PE, proportion of cases treated with anticoagulation alone, systemic thrombolysis, and directed therapy (local thrombolysis and thrombectomy), clinical outcomes, and total costs. Methods A multicenter observational study was performed using administrative data from the Pediatric Health Information System database to study PE treated at U.S. pediatric hospitals from 2015 to 2021. Outcomes by treatment were evaluated using multivariable generalized linear mixed effects models. Results Of 3,136 subjects, 70% were at least 12 years of age, and 46% were male. Sixty-two percent had at least 1 comorbidity, and congenital heart disease of any kind was the most prevalent (20%). Eighty-eight percent of subjects received anticoagulation alone, 7% received systemic thrombolysis, and 5% received directed therapy. Overall in-hospital mortality was 7.5%. Treatment approach did not change over time (P = 0.98). After adjusting for patient characteristics, directed therapy was associated with a lower risk of mortality (adjusted percentage -3%, [95% CI: -5% to 0%]) than anticoagulation alone. Systemic thrombolysis was associated with a greater total cost of hospitalization ($113,043 greater [95% CI: $62,866, $163,219]). Length of hospital stay did not differ by treatment. Conclusions Pediatric patients with PE have a high incidence of underlying chronic disease. Anticoagulation alone remains the mainstay of treatment, with thrombolysis and thrombectomy rarely being used. Given the relative rarity of pediatric PE, additional research requiring innovative study designs is paramount.
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Affiliation(s)
- Radhika Rastogi
- Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Oluwatimilehin Okunowo
- Division of Biostatistics, Department of Computational and Quantitative Medicine, Beckman Research Institute of City of Hope, Duarte, California, USA
| | - Jennifer A. Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Constantine D. Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hilary Whitworth
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Therese M. Giglia
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Char Witmer
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leslie J. Raffini
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael L. O'Byrne
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Clinical Futures, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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8
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Watson NW, Carroll BJ, Krawisz A, Schmaier A, Secemsky EA. Trends in Discharge Rates for Acute Pulmonary Embolism in U.S. Emergency Departments. Ann Intern Med 2024; 177:134-143. [PMID: 38285986 DOI: 10.7326/m23-2442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Outpatient management of select patients with low-risk acute pulmonary embolism (PE) has been proven to be safe and effective, yet recent evidence suggests that patients are still managed with hospitalization. Few studies have assessed contemporary real-world trends in discharge rates from U.S. emergency departments (EDs) for acute PE. OBJECTIVE To evaluate whether the proportion of discharges from EDs for acute PE changed between 2012 and 2020 and which baseline characteristics are associated with ED discharge. DESIGN Serial cross-sectional analysis. SETTING U.S. EDs participating in the National Hospital Ambulatory Medical Care Survey. PATIENTS Patients with ED visits for acute PE between 2012 and 2020. MEASUREMENTS National trends in the proportion of discharges for acute PE and factors associated with ED discharge. RESULTS Between 2012 and 2020, there were approximately 1 635 300 visits for acute PE. Overall, ED discharge rates remained constant over time, with rates of 38.2% (95% CI, 17.9% to 64.0%) between 2012 and 2014 and 33.4% (CI, 21.0% to 49.0%) between 2018 and 2020 (adjusted risk ratio, 1.01 per year [CI, 0.89 to 1.14]). No baseline characteristics, including established risk stratification scores, were predictive of an increased likelihood of ED discharge; however, patients at teaching hospitals and those with private insurance were more likely to receive oral anticoagulation at discharge. Only 35.9% (CI, 23.9% to 50.0%) of patients who were considered low-risk according to their Pulmonary Embolism Severity Index (PESI) class, 33.1% (CI, 21.6% to 47.0%) according to simplified PESI score, and 34.8% (CI, 23.3% to 48.0%) according to hemodynamic stability were discharged from the ED setting. LIMITATIONS Cross-sectional survey design and inability to adjudicate diagnoses. CONCLUSION In a representative nationwide sample, rates of discharge from the ED for acute PE appear to have remained constant between 2012 and 2020. Only one third of low-risk patients were discharged for outpatient management, and rates seem to have stabilized. Outpatient management of low-risk acute PE may still be largely underutilized in the United States. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Nathan W Watson
- Harvard Medical School, and Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (N.W.W.)
| | - Brett J Carroll
- Harvard Medical School; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center; and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (B.J.C., A.K., E.A.S.)
| | - Anna Krawisz
- Harvard Medical School; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center; and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (B.J.C., A.K., E.A.S.)
| | - Alec Schmaier
- Harvard Medical School, and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (A.S.)
| | - Eric A Secemsky
- Harvard Medical School; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center; and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (B.J.C., A.K., E.A.S.)
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9
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Gonsalves CF, Gibson CM, Stortecky S, Alvarez RA, Beam DM, Horowitz JM, Silver MJ, Toma C, Rundback JH, Rosenberg SP, Markovitz CD, Tu T, Jaber WA. Randomized controlled trial of mechanical thrombectomy vs catheter-directed thrombolysis for acute hemodynamically stable pulmonary embolism: Rationale and design of the PEERLESS study. Am Heart J 2023; 266:128-137. [PMID: 37703948 DOI: 10.1016/j.ahj.2023.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND The identification of hemodynamically stable pulmonary embolism (PE) patients who may benefit from advanced treatment beyond anticoagulation is unclear. However, when intervention is deemed necessary by the PE patient's care team, data to select the most advantageous interventional treatment option are lacking. Limiting factors include major bleeding risks with systemic and locally delivered thrombolytics and the overall lack of randomized controlled trial (RCT) data for interventional treatment strategies. Considering the expansion of the pulmonary embolism response team (PERT) model, corresponding rise in interventional treatment, and number of thrombolytic and nonthrombolytic catheter-directed devices coming to market, robust evidence is needed to identify the safest and most effective interventional option for patients. METHODS The PEERLESS study (ClinicalTrials.gov identifier: NCT05111613) is a currently enrolling multinational RCT comparing large-bore mechanical thrombectomy (MT) with the FlowTriever System (Inari Medical, Irvine, CA) vs catheter-directed thrombolysis (CDT). A total of 550 hemodynamically stable PE patients with right ventricular (RV) dysfunction and additional clinical risk factors will undergo 1:1 randomization. Up to 150 additional patients with absolute thrombolytic contraindications may be enrolled into a nonrandomized MT cohort for separate analysis. The primary end point will be assessed at hospital discharge or 7 days post procedure, whichever is sooner, and is a composite of the following clinical outcomes constructed as a hierarchal win ratio: (1) all-cause mortality, (2) intracranial hemorrhage, (3) major bleeding, (4) clinical deterioration and/or escalation to bailout, and (5) intensive care unit admission and length of stay. The first 4 components of the win ratio will be adjudicated by a Clinical Events Committee, and all components will be assessed individually as secondary end points. Other key secondary end points include all-cause mortality and readmission within 30 days of procedure and device- and drug-related serious adverse events through the 30-day visit. IMPLICATIONS PEERLESS is the first RCT to compare 2 different interventional treatment strategies for hemodynamically stable PE and results will inform strategy selection after the physician or PERT determines advanced therapy is warranted.
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Affiliation(s)
| | | | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | | | - Daren M Beam
- Indiana University Health University Hospital, Indianapolis, IN
| | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John H Rundback
- Advanced Interventional & Vascular Services, LLP, Teaneck, NJ
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10
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Farmakis IT, Barco S, Giannakoulas G, Keller K, Valerio L, Tichelbäcker T, Partovi S, Ahrens I, Konstantinides SV, Hobohm L. A nationwide analysis of reperfusion therapies for pulmonary embolism in older patients with frailty. EUROINTERVENTION 2023; 19:772-781. [PMID: 37767997 PMCID: PMC10654770 DOI: 10.4244/eij-d-23-00399] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/15/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic thrombolysis (ST) is contraindicated or has failed. Their safety has not been evaluated in specific vulnerable populations. AIMS We aimed to assess the safety of reperfusion therapies in elderly and frail patients in the real world. METHODS In the US Nationwide Inpatient Sample from 2016 to 2020, we identified hospitalisations of patients ≥65 years with PE and defined a frailty subgroup using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We investigated reperfusion therapies (ST, catheter-directed thrombolysis [CDT], catheter-based thrombectomy [CBT], surgical embolectomy [SE]) and their associated safety outcomes (overall and major bleeding). RESULTS Among 980,245 hospitalisations of patients ≥65 years with PE (28.0% frail), reperfusion therapies were used in 4.9% (17.6% among high-risk PE). ST utilisation remained stable, while the use of catheter-directed therapies increased from 1.7% in 2016 to 3.2% in 2020. Among all hospitalisations with reperfusion, CDT, compared to ST, was associated with reduced major bleeding (5.8% vs 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70); these results also applied to frail patients. CBT, compared to SE, was also associated with reduced major bleeding (11.0% vs 22.4%, OR 0.63, 95% CI: 0.43-0.91), but not among frail patients. These differences were particularly significant in patients with non-high-risk PE. Differences persisted for overall bleeding as well. CONCLUSIONS Catheter-directed therapies may be a safer alternative to classical reperfusion therapies for elderly and frail patients with PE requiring reperfusion treatment.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - George Giannakoulas
- Department of Cardiology, AHEPA University General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Tobias Tichelbäcker
- Clinic III for Internal Medicine, Heart Centre of University Hospital of Cologne, Cologne, Germany
| | - Sasan Partovi
- Interventional Radiology Section, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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11
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Monteleone P, Thangam M. Who Is Dying of Pulmonary Embolism? Am J Cardiol 2023; 207:490-492. [PMID: 37833167 DOI: 10.1016/j.amjcard.2023.08.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Peter Monteleone
- Department of Cardiovascular Medicine, University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas.
| | - Manoj Thangam
- Department of Cardiovascular Medicine, University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas
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12
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Abrignani MG. The Year 2022 in Cardiovascular Diseases- Clinics and Practice. Clin Pract 2023; 13:763-767. [PMID: 37489418 PMCID: PMC10366779 DOI: 10.3390/clinpract13040069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023] Open
Abstract
This journal has recently achieved significant milestones, receiving its first impact factor of 2 [...].
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Affiliation(s)
- Maurizio G Abrignani
- Operative Unit of Cardiology, P. Borsellino Hospital, Marsala, ASP Trapani, 91016 Erice, Italy
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13
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Casipit B, Tito S, Ogunmola I, Idowu A, Patil S, Lo K, Bozorgnia B. Outcomes among heart failure patients hospitalized for acute pulmonary embolism and COVID-19 infection: Insight from the National Inpatient Sample. Pulm Circ 2023; 13:e12229. [PMID: 37091122 PMCID: PMC10113514 DOI: 10.1002/pul2.12229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/24/2023] [Accepted: 04/09/2023] [Indexed: 04/25/2023] Open
Abstract
There is paucity of data regarding the outcomes of hospitalized acute pulmonary embolism (PE) patients with heart failure (HF) and Coronavirus Disease 2019 (COVID-19) infection. We utilized the 2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study to investigate the outcomes of hospitalized acute PE patients with HF and COVID-19, looking at its impact on in-hospital mortality, thrombolysis, and thrombectomy utilization as well as hospital length of stay (LOS). A total of 23,413 hospitalized acute PE patients with HF were identified in our study, of which 1.26% (n = 295/23,413) had COVID-19 infection. Utilizing a stepwise survey multivariable logistic regression model that adjusted for confounders, COVID-19 infection among acute PE patients with HF was found to be an independent predictor of overall in-hospital mortality (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI], 1.15-6.67; p = 0.023) and thrombolysis utilization (aOR: 5.52; 95% CI, 2.57-11.84; p ≤ 0.001) compared to those without COVID-19. However, there were comparable rates of thrombectomy utilization and LOS among acute PE patients with HF regardless of the COVID-19 infection status. On subgroup analysis, patients with HF with reduced ejection fraction was found to be associated with increased risk for in-hospital mortality (aOR: 3.89; 95% CI, 1.33-11.39; p = 0.013) and thrombectomy utilization (aOR: 4.58; 95% CI, 1.08-19.41; p = 0.042), whereas both HF subtypes were associated with increased thrombolysis utilization. COVID-19 infection among acute PE patients with HF was associated with higher over-all in-hospital mortality and increased thrombolysis utilization but had comparable hospital LOS as well as thrombectomy utilization.
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Affiliation(s)
- Bruce Casipit
- Department of MedicineEinstein Medical CenterPhiladelphiaUSA
- Department of Cardiovascular DiseaseEinstein Medical CenterPhiladelphiaUSA
| | - Sahana Tito
- Department of MedicineEinstein Medical CenterPhiladelphiaUSA
- Department of Cardiovascular DiseaseEinstein Medical CenterPhiladelphiaUSA
| | - Isaac Ogunmola
- Department of MedicineEinstein Medical CenterPhiladelphiaUSA
- Department of Cardiovascular DiseaseEinstein Medical CenterPhiladelphiaUSA
| | - Abiodun Idowu
- Department of MedicineEinstein Medical CenterPhiladelphiaUSA
- Department of Cardiovascular DiseaseEinstein Medical CenterPhiladelphiaUSA
| | - Shivaraj Patil
- Department of Cardiovascular DiseaseEinstein Medical CenterPhiladelphiaUSA
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Kevin Lo
- Department of MedicineEinstein Medical CenterPhiladelphiaUSA
- Department of Cardiovascular DiseaseEinstein Medical CenterPhiladelphiaUSA
| | - Behnam Bozorgnia
- Department of Cardiovascular DiseaseEinstein Medical CenterPhiladelphiaUSA
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
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14
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Kumar G, Jaber W, Sachdeva R. Intravascular ultrasound guidance in percutaneous mechanical thrombectomy: A single-center experience from the FLASH registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 50:19-25. [PMID: 36697337 DOI: 10.1016/j.carrev.2023.01.011] [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: 11/24/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Traditionally, iodinated contrast is utilized during catheter-based mechanical thrombectomy for pulmonary embolism (PE). Recently, there have been disruptive contrast shortages. Furthermore, contrast can cause contrast-induced acute kidney injury especially in patients with pre-existing chronic kidney disease, necessitating an alternative imaging method. We present utilization and feasibility of an intravascular ultrasound (IVUS)-guided strategy for mechanical thrombectomy in PE from the FLASH registry. METHODS In this FLASH patient subset, IVUS was used to image the pulmonary arteries (PAs) before and after mechanical thrombectomy with the FlowTriever System at one study site comprising three hospitals. The Philips Visions PV 0.035" IVUS catheter was used for all the IVUS-guided cases in a standardized manner. RESULTS Between July 2019 and December 2021, 26 FLASH patients enrolled at this site underwent IVUS-guided thrombectomy. Most patients (96.2 %) had intermediate-risk PE and 3.8 % had high-risk PE. The mean baseline composite RV/LV ratio was 1.36 ± 0.27 and the mean simplified Pulmonary Embolism Severity Index (sPESI) score was 1.9 ± 1.2. A decreasing trend in contrast agent volume usage was observed over time and several later procedures were performed with IVUS guidance alone. Mean PA pressure significantly decreased immediately following thrombectomy from 34.8 ± 8.3 to 25.5 ± 7.3 mmHg (p < 0.0001). Systolic PA pressure also significantly decreased immediately from 55.4 ± 13.9 to 39.5 ± 12.5 mmHg (p < 0.0001). Significant improvements were seen in echocardiographic assessments of RV function at a mean 87-day follow-up compared with baseline. CONCLUSIONS In conclusion, the use of IVUS guidance with minimal or no angiographic contrast during mechanical thrombectomy for acute PE is technically feasible.
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Affiliation(s)
- Gautam Kumar
- Division of Cardiology, Emory University Hospital, Atlanta, GA, United States of America; Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States of America
| | - Wissam Jaber
- Division of Cardiology, Emory University Hospital, Atlanta, GA, United States of America
| | - Rajesh Sachdeva
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA, United States of America.
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15
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Muacevic A, Adler JR. Outcomes of Surgical and Mechanical Thrombectomy in Massive Saddle Pulmonary Embolism: A National Perspective. Cureus 2022; 14:e29885. [PMID: 36348926 PMCID: PMC9629997 DOI: 10.7759/cureus.29885] [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] [Accepted: 09/25/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Saddle pulmonary embolism (PE) is a type of central PE that involves the bifurcation of the pulmonary arteries. First-line treatment is usually systemic thrombolytics, but surgical and mechanical thrombectomy (ST and MT) are used for patients with contraindications to thrombolytics or right heart strain. This study compares surgical and mechanical thrombectomy trends and outcomes in patients with saddle PE. Methods The data was extracted from the National In-Patient Sample (NIS) from 2016-2018 using the International Classification of Diseases-10-Clinical Modification (ICD-10-CM) diagnosis codes. We used the Cochrane-Armitage trend test to analyze the trends of ST and MT and the chi-square test for statistical analyses. A two-tailed p-value of <0.05 was considered statistically significant. Results The overall trend of MT in saddle PE rose from 2016 to 2018, while ST remained stable. Around 95% of patients undergoing ST/MT were emergent admissions, with 82.5% occurring in teaching hospitals. Patients of age >65 years and more with comorbidity burdens were more likely to undergo MT over ST. In-hospital mortality after ST was 15.1%, and after MT was 11.1% (p:<0.001). The most common complications after ST were congestive heart failure (CHF) and atrial fibrillation (AF), and after MT were vascular events and CHF. Conclusion The use of mechanical thrombectomy has steadily increased during the study period. ST is more common in large/teaching hospitals, weekend admissions, and patients transferred from other facilities. MT is more common in elderly patients with a higher comorbidity burden. Patients who underwent MT had lower mortality, length of hospital stay, and post-procedural complications.
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