A Survey of Submassive Pulmonary Embolism Treatment Preferences among Medical and Endovascular Physicians

Safety of Therapeutic Anticoagulation with Low-Molecular-Weight Heparin or Unfractionated Heparin Infusion during Catheter-Directed Thrombolysis for Acute Pulmonary Embolism

PURPOSE

To examine the safety of therapeutic-dose anticoagulation during catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE).

MATERIALS AND METHODS

A retrospective review of 156 consecutive cases (age, 56.6 ± 15.4 years; 85 males) of CDT with alteplase for acute PE (symptoms, <14 days) between 2009 and 2019 was performed. All patients received full-dose anticoagulation before, during, and after thrombolysis with low-molecular-weight heparin (LMWH) (n = 45) or unfractionated heparin (n = 111) infusion. Massive PE was diagnosed in 21 of 156 patients at presentation; submassive PE was diagnosed in 135 of 156 patients at presentation. The Simplified Pulmonary Embolism Severity Index was ≥1 in 69 of 156 patients.

RESULTS

There were 4 mild (2.6%), 3 moderate (1.9%), and 3 severe (1.9%) hemorrhagic complications (Global Use of Strategies to Open Occluded Arteries), 1 of which (0.6%) was intracranial. No significant differences in hemorrhagic complication rates (P = .3, P = 1.0, and P = .6, respectively) or general complication rates (Society of Interventional Radiology [SIR] minor, P = .2; SIR major, P = .7) were noted between the LMWH and heparin groups. Mean pulmonary arterial pressure for the entire cohort improved from 28.9 ± 7.6 mmHg to 20.4 ± 6.5 mmHg (P < .001), whereas the Miller score improved from 19.3 ± 4.6 to 7.3 ± 3.9 (P < .001). The average infusion duration was 26 ± 11.9 hours over 2.3 ± 0.6 total visits to the angiography lab, during which a mean of 27.85 ± 14.2 mg of tissue plasminogen activator were infused.

CONCLUSIONS

Therapeutic anticoagulation during CDT for PE appears to be safe. The current study did not find a significant difference between LMWH and heparin infusion with respect to hemorrhagic and general complication rates.

Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.

How the Results of a Randomized Trial of Catheter-Directed Thrombolysis Versus Anticoagulation alone for Submassive Pulmonary Embolism Would Affect Patient and Physician Decision Making: Report of an Online Survey

The purpose is to investigate how the outcomes of a randomized controlled trial (RCT) of catheter-directed thrombolysis (CDT) versus anticoagulation alone for acute submassive PE would affect clinical decision-making. An online survey was sent to the Pulmonary Embolism Response Team Consortium members and the North American Thrombosis Forum members. Participants rated their preference for CDT on a 5-point scale in 5 RCT outcome scenarios. In all scenarios, subjects in the CDT group walked farther at 1-year than those in the anticoagulation group. A total of 83.3% of patients and 67.1% of physicians preferred CDT (score > 3) if it improved exercise capacity and did not increase bleeding. In every scenario, patients scored CDT higher than physicians (p < 0.05 for each). Bleeding and clinical deterioration were independently associated with the mean score. Patients’ age, gender, and history of PE did not influence CDT scores (p = 0.083, p = 0.071, p = 0.257 respectively). For patients, 60% > 60 years, 65.5% < 60 years, 57.1% of men, and 66.3% of women preferred CDT across scenarios. In conclusion, the majority of respondents would choose CDT if it improves long-term exercise capacity and does not increase bleeding. Patients appear to accept a higher bleeding risk than physicians if CDT improves long-term exercise capacity.

Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT)

Pulmonary embolism (PE) is a potentially fatal disease with a broad range of treatment options that spans multiple specialties. The rapid evolution and expansion of novel therapies to treat PE make it a disease process that is well suited to a multidisciplinary approach. In order to facilitate a rapid, robust response to the diagnosis of PE, some hospitals have established multidisciplinary pulmonary embolism response teams (PERTs). The PERT model is based on existing multidisciplinary teams such as heart teams and rapid response teams. A PERT is composed of clinicians from the range of specialties involved in the treatment of PE, including pulmonology critical care, interventional radiology, cardiology, and cardiothoracic surgery among others. A PERT is a 24/7 consult service that is able to provide expert advice on the initial management of PE patients and convene in real time to develop a consensus treatment plan specifically tailored to the needs of a particular patient and consistent with the capabilities of the institution. In this review, we discuss the rationale for establishing a PERT and its potential benefits. We discuss considerations in forming a PERT and present case studies of several PERTs currently in operation at different institutions. We also discuss potential difficulties in forming a PERT and review evidence that has been generated by some of the PERTs that have been in operation the longest.