Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association

Plasma D-dimer changes and clinical value in acute lower extremity deep venous thrombosis treated with catheter-directed thrombolysis

OBJECTIVE

This study sought to investigate the changes in plasma D-dimer levels during catheter-directed thrombolysis (CDT) in patients with acute lower extremity deep venous thrombosis (DVT), analyze imaging results, and assess their clinical implications.

METHODS

We retrospectively analyzed 62 patients diagnosed with acute lower extremity DVT who underwent CDT between March 2019 and December 2022. Plasma D-dimer levels were measured before CDT, at regular intervals after CDT, and at the end of CDT. Lower limb venography was performed every 2 days during CDT to assess the thrombus clearance rate and level of thrombus dissolution. Statistical analyses were conducted to observe the D-dimer concentration changes and analyze the correlation between D-dimer concentration and thrombus clearance rate. Additionally, a receiver operating characteristic curve was constructed to determine the diagnostic performance of D-dimer in assessing the efficacy of thrombolysis, including the calculation of the area under the curve, sensitivity, specificity, and optimal cut-off value.

RESULTS

During CDT for acute lower extremity DVT, plasma D-dimer levels rapidly increased, peaking on CDT day 1, and then gradually decreased, followed by a rapid decline, but remained slightly elevated compared with normal levels. There was a positive correlation between D-dimer levels and thrombolysis efficacy (r = 0.809; P = .00). The linear regression equation for this correlation was Y = 0.161 + 0.028X. The area under the curve of D-dimer was 0.95, with a cut-off value of 9.935 mg/L (sensitivity, 93.2%; specificity, 95.4%).

CONCLUSIONS

Plasma D-dimer concentration can serve as an indicator for evaluating the efficacy of thrombolysis during CDT in acute lower extremity DVT.

Graded response of the pulmonary circulation to progressive pulmonary embolism in sheep: From compensation to lethal right heart failure

Background

Severe pulmonary embolism (PE) with right heart failure (RHF) has high mortality. To more fully understand PE progression, we evaluated the right ventricle (RV) and pulmonary circulation response to graded PE in an acute PE sheep model.

Methods

Polydextran beads were intravenously administered every 15 minutes in 250 mg doses to adult female sheep (n = 8) until death. Concurrent pulmonary artery (PA) blood flow/pressure was measured. RV pressure-volume (P-V) loops were generated with a conductance catheter. Pulmonary vascular resistance was used to stage PE severity into mild, moderate, and severe groups.

Results

All sheep developed graded RHF. For mild, moderate, and severe PE, 3, 6, and 9 doses were needed, respectively. Only 1 additional dose triggered death. In severe PE, mean PA pressure reached 42 ± 6 mm Hg with significantly decreased cardiac output (CO). Pulmonary impedance spectra showed significantly increased Z0 (RV static load) and Z1 (RV pulsatile load). PE shifted the RV P-V loop from lower left triangular to upper right rectangular shape. PA elastance (Ea, RV afterload) and end-systolic elastance (Ees, RV contractility) progressively increased. Ees/Ea (RV-PA coupling) was initially maintained but became uncoupled in severe PE, causing RHF.

Conclusions

Compensatory increases in RV contractility initially maintain CO in PE despite RV afterload elevation. Increased RV contractility eventually fails to compensate for elevated RV afterload, causing RV-PA uncoupling in severe PE with RHF. Severe PE rapidly progresses to lethal RHF and will likely require immediate intervention to prevent death.

Comparison of safety and efficacy of ultrasound-accelerated thrombolysis vs. standard catheter-directed thrombolysis for the management of acute pulmonary embolism - a systematic review and meta-analysis

Standard catheter-directed thrombolysis (SCDT) and Ultrasound-assisted thrombolysis (USAT) are used in intermediate and high-risk pulmonary embolism (PE). SCDT uses low-dose thrombolytic agents, minimizing bleeding risk. USAT adds acoustic energy to improve fibrin breakdown and thrombolytic penetration. A systematic literature search spanning PubMed/Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov databases (from inception to 17 June 2024) was conducted to retrieve studies comparing USAT to SCDT for managing acute PE. Risk of bias was assessed using Cochrane tools for randomized and non-randomized trials. Odds ratio (OR) and mean difference (MD) were pooled using random effects models. Statistical analyses were performed in R version 4.2.2. 11 studies with 37,398 patients (8,762: USAT and 28,636: SCDT) were included. The mean reduction in right ventricular to left ventricular diameter ratio was lower for USAT (MD: -0.12; 95% CI: -0.19, -0.06) compared to SCDT. There was no statistically significant difference between USAT and SCDT for odds of in-hospital mortality, intracranial hemorrhage, bleeding requiring transfusion or for means of hospital or ICU length of stay, or reduction in pulmonary artery pressures. Safety or efficacy of USAT is not superior to SCDT in patients with acute PE. Results were limited due to variable infusion protocol across studies and heterogeneity of results among studies. Large-scale randomized controlled trials (RCTs) are needed to corroborate these findings.

Impact of coincident lower extremity deep vein thrombosis on symptomatic and incidental pulmonary embolism outcomes. A single-center prospective cohort study

BACKGROUND

The prognostic implications of co-incident DVT at the time of PE diagnosis remains unclear.

OBJECTIVES

Study aims were to assess the impact of co-incident lower extremity (LE) deep vein thrombosis (DVT) on clinical outcomes of pulmonary embolism (PE) including venous thromboembolism (VTE) recurrence and mortality.

METHODS

Consecutive patients with confirmed acute symptomatic or incidental PE (March 1, 2013 to June 30, 2021) who underwent ultrasound imaging were divided into two groups depending on the presence or absence of LE DVT. Patients were followed prospectively for VTE recurrence, bleeding, and all-cause mortality.

RESULTS

Over the study period, 1907 patients with PE were stratified into groups based on the presence (n = 920) or absence (n = 987) of LE DVT. Patients with co-incident LE DVT were older, heavier, and had a significantly greater frequency of trauma, confinement, thrombophilia, and VTE. Those without LE DVT had a higher prevalence of active cancer, metastatic disease, and active systemic therapy use. All-cause mortality rates (per 100 person-years) were significantly higher for patients without vs with co-incident LE DVT (42.4/100 person-years vs 29.6/100 person- years; P < .001) with no differences in VTE recurrence or bleeding outcomes. After stratification by cancer status, mortality in those without vs. with co-incident DVT only remained significant among noncancer patients (15.2/100 person-years vs 12.1/100 person-years, P = .046).

CONCLUSIONS

Among patients with acute PE, the absence of co-incident lower extremity DVT is associated with significantly higher mortality rates. Mortality rate differences were only observed for those without cancer. No differences in VTE recurrence or bleeding were observed.

Additive Value of Right Ventricular Global Longitudinal Strain to a Conventional Echocardiographic Parameter to Improve Prognostic Value in Intermediate-Risk Pulmonary Embolism

BACKGROUND

Right ventricular (RV) dysfunction has been identified as a prognostic marker for adverse events in patients with intermediate-risk pulmonary embolism. We hypothesized that right-sided strain parameters have additive value to conventional echocardiographic parameters to further risk-stratify patients for mortality.

METHODS AND RESULTS

This is a retrospective cohort study of patients with intermediate-risk pulmonary embolism between 2010 and 2018. All-cause 30-day mortality was evaluated. Echocardiographic strain parameters and conventional RV measurements were compared between survivors and nonsurvivors. Two hundred fifty-one patients were analyzed. Mortality at 30 days was 12.4%. Image quality was sufficient for RV strain analysis in 230 patients (91.6%). Right to left ventricular end-diastolic diameter ratio (RV/LV ratio) (odds ratio [OR], 1.490 [95% CI, 1.120-1.990]) and RV global longitudinal strain (RVGLS) (OR, 0.742 [95% CI, 0.605-0.910]) were independently associated with 30-day mortality. Using RVGLS and RV/LV ratio in an additive fashion, we found that 99 patients with a high RVGLS (>17.7%) and low RV/LV ratio (<1.03) had a 30-day mortality of 1.0%. Conversely, 39 patients with a low RVGLS (≤17.7%) and high RV/LV ratio (≥1.03) had a 30-day mortality of 46.2%. Kaplan-Meier analysis depicted the significantly different prognosis among the groups (P<0.001).

CONCLUSIONS

The combined evaluation of RVGLS and RV/LV ratio is a practical method of evaluating RV dysfunction. Using both parameters in patients with intermediate-risk pulmonary embolism identifies those at highest and lowest risk of short-term mortality. This approach offers promise for improved risk stratification and guidance of treatment pathways.

Syringe-assisted test-aspiration with mechanical aspiration thrombectomy results in good safety and short-term outcomes in the treatment of patients with deep venous thrombosis

ObjectiveTo evaluate the short-term outcomes and safety of syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis.MethodsThis was a single-center, retrospective study of hospitalized patients with iliofemoral and/or inferior vena caval deep venous thrombosis, excluding those with pulmonary embolism. We collected the following patient data from the electronic medical records: age, sex, provoked/unprovoked deep venous thrombosis, symptom duration, thrombosed segments, and the presence of a tumor, thrombophilia, diabetes, and/or iliac vein compression syndrome. Venography and computed tomographic venography were performed in all patients before the procedure. All patients underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy under local anesthesia and sedation, and all received low-molecular-weight heparin peri-operatively. All patients underwent implantation of an inferior vena caval filter. Rivaroxaban was administered post-procedure, instead of heparin, for 3-6 months, with lower extremity compression.ResultsOverall, 29 patients with deep venous thrombosis underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy from January 2022 to October 2022 in our institution. Technical success (>70% thrombus resolution) was achieved in all patients, and using a single procedure in 25/29 patients (86%). Concomitant stenting was performed in 18/29 (62%) of the patients, and 21/29 (69%) underwent angioplasty. The median (interquartile range) procedure time was 110 min (100-122), the median intra-operative bleeding volume was 150 mL (120-180), and the median decrease in the hemoglobin concentration from pre- to post-operative was 7 g/L (4-14). The median follow-up duration was 7 months (5-9). All patients obtained symptomatic relief, and 27/29 achieved near-remission or full remission (combined total). No patients experienced peri-operative bleeding complications, or symptom recurrence or post-thrombectomy syndrome during follow-up.ConclusionThe short-term outcomes following syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis were excellent, and the procedure was safe.

Long-term mortality from imaging-diagnosed pulmonary embolism in women and men

Pulmonary embolism (PE) is a heterogeneous disease with variable severity. Risk factors and occurrence of PE differ in patients by gender, age, and comorbidity. Our goal was to determine long-term mortality in imaging diagnosed PE in men and women while accounting for differences in age and health status. This was a retrospective study of adults imaged for PE with ventilation/perfusion scintigraphy or CT pulmonary angiography over a 7-year period at our multisite urban academic medical center. Electronic health records (EHR) were reviewed for patient data, including Charlson comorbidity index (CCI). Mortality at one-year was determined from EHR and National Death Index. Association between PE and survival was assessed using Cox proportional hazard model. 33,628 patients (55yo ± 19, 69 % women) were imaged for PE, 9.5 % of exams were positive. One-year mortality for the cohort was 9.9 % for women vs. 16.8 % for men, p < 0.001. Women with PE had higher increased one-year mortality (HR 2.75[2.48-3.06]) than men with PE (HR:1.38[1.21-1.58]). Women with PE also had higher hazard ratio after inclusion of age and CCI as covariates in the Cox proportional hazard model (women HR 1.68 [1.51-1.86] versus men HR 1.20 [1.05-1.36]). The higher impact of PE on the mortality of women yielded a similar one-year mortality for women and men with PE, 21.9 % vs. 21.5 %, respectively (P = 0.83). Positive PE study was associated with significantly increased one-year mortality, however this effect was much stronger in women. This gender difference persists after accounting for age and comorbidities.

Percutaneous thrombectomy of fat embolism in-transit

We report the case of a previously independent 82-year-old female who experienced acute hemodynamic and respiratory deterioration requiring inotropic support due to a fat embolism during revision hip arthroplasty. Computed tomography pulmonary angiography demonstrated fat embolism, and transesophageal echocardiogram showed evidence of right ventricle strain and fat embolism in-transit in the right heart, as well as a moderate patent foramen ovale. Under transesophageal echocardiogram and intravascular ultrasound guidance, the Inari FlowTriever thrombectomy device was used successfully to retrieve the fat embolism with immediate hemodynamic improvement, no complications, and uneventful recovery.

A prospective, multicenter, randomized controlled trial evaluating anticoagulation alone vs anticoagulation plus computer assisted vacuum thrombectomy for the treatment of intermediate-high-risk acute pulmonary embolism: Rationale and design of the STORM-PE study

BACKGROUND

Therapeutic anticoagulation (AC) is standard care for pulmonary embolism (PE). Endovascular therapy with mechanical thrombectomy (MT) is commonly performed for PE and well-studied in single-arm trials. The efficacy benefit of MT over AC alone in a randomized fashion remains unstudied.

METHODS AND RESULTS

STORM-PE (ClinicalTrials.gov Identifier: NCT05684796) is a post-market, international, open-label trial conducted in partnership with The Pulmonary Embolism Response Team ConsortiumTM. Up to 100 patients with confirmed acute intermediate-high-risk PE demonstrated by right ventricular (RV) dysfunction with a right-to-left ventricular (RV/LV) ratio ≥1.0 and elevated cardiac biomarkers will be randomized 1:1 to receive AC alone or AC plus Computer Assisted Vacuum Thrombectomy (CAVT) with the Indigo Aspiration System (Penumbra Inc.). The primary outcome is a mean change in RV/LV ratio at 48 hours, assessed by computed tomographic pulmonary angiography (CTPA) and adjudicated by a blinded, independent imaging Core Lab. Additional endpoints are composite major adverse events, functional outcomes (6-minute walk test, New York Heart Association classification, post-venous thromboembolism functional status scale, modified Medical Research Council Dyspnea Scale, Borg Scale), quality of life (Pulmonary Embolism Quality of Life Questionnaire and EQ-5D-5L), mortality, and symptomatic PE recurrence through 90 days. A Clinical Events Committee will adjudicate adverse events for causality and attribution and an independent Data Safety Monitoring Board will oversee the study. STORM-PE is funded by Penumbra Inc.

CONCLUSIONS

The STORM-PE trial will help inform future guidelines and standards of care related to frontline treatment using mechanical thrombectomy with CAVT for patients with acute intermediate-high-risk PE.

TRIAL REGISTRATION

STORM-PE, NCT05684796, is registered at https://clinicaltrials.gov/study/NCT05684796.

Gender disparity in clinical and management outcomes in patients with pulmonary embolism: a systematic review and meta-analysis

Background

Gender may contribute significantly to the variation in prognostic aspects and outcomes in various clinical conditions. We reviewed original studies to determine the impact of gender on the clinical outcomes in patients with pulmonary embolism.

Methods

A systematic review and meta-analysis synthesizing observational studies was conducted by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through April 12, 2023. We reported dichotomous outcomes using risk ratio (RR) and the corresponding 95% confidence interval (CI).

Results

We included 18 studies with a total of 1,339,937 patients. There was no difference between men and women for all-cause mortality (RR: 0.99; 95% CI [0.89, 1.10]; P = 0.81), in-hospital mortality (RR: 0.94; 95% CI [0.88, 1.02]; P = 0.13), PE-related mortality (RR: 0.86; 95% CI [0.68, 1.09]; P = 0.21), and recurrence (RR: 1.00; 95% CI [0.82, 1.22]; P = 0.99). However, the major bleeding rate was significantly higher among women (RR: 0.69; 95% CI [0.48, 0.98]; P = 0.04), as was hospital length of stay (mean difference: -0.29; 95% CI: [-0.36, -0.22], P < 0.00001; I2= 96%). Also, there was no difference between men and women regarding catheter-directed thrombolysis (RR: 0.96; 95% CI [0.81, 1.14]; P = 0.66) and risk of heparin infusion (RR: 1.00; 95% CI [0.95, 1.04]; P = 0.90).

Conclusion

There was no difference between men and women for the clinical outcomes and management of PE. However, women undergoing treatment for pulmonary thromboembolic disease had a significantly higher risk of major bleeding and longer length of stay compared to men. Further research is required to investigate the reasons behind these differences and assess their potential impact on patient management and prognosis.

Anticoagulation alone versus large-bore mechanical thrombectomy in acute intermediate-risk pulmonary embolism

BACKGROUND

Patients with intermediate-risk pulmonary embolism (PE) have outcomes worse than uncomplicated ST elevation myocardial infarction. Yet, no large-scale study has compared the outcomes of large-bore mechanical thrombectomy (LBMT) with anticoagulation alone (AC). The aim of this study was to compare the clinical outcomes among patients receiving LBMT vs AC alone.

METHODS

This was a two-center retrospective study that included patients with intermediate-risk PE from October 2016 - October 2023 from the institution's Pulmonary Embolism Response Team (PERT) database. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest or hemodynamic decompensation. Inverse probability of treatment weighting (IPTW) was used to balance covariates; Kaplan Meir curves and IPTW multivariable Cox regression were used to assess the relationship between treatment groups and outcomes.

RESULTS

Of the 273 patients included in the analysis, 192 (70 %) patients received AC alone and 81 (30 %) patients received LBMT and AC. A total of 30 (10.9 %) patients experienced the primary composite outcome over a median follow-up of 30 days. The primary composite outcome was significantly lower in the group that received LBMT compared to those on AC alone (1.2 % vs 15.1 %, log-rank p < 0.001; adjusted HR: 0.02; 95 % CI: 0.002-0.17, p < 0.001) driven by a lower rate of 30-day all-cause mortality (0 % vs 7.3 %, log-rank p = 0.01), resuscitated cardiac arrest (0 % vs 6.8 %, log-rank p = 0.016) and new or worsening hemodynamic instability (4 % vs 11.1 %, log-rank p = 0.007).

CONCLUSION

In this largest cohort to date comparing LBMT versus AC alone in acute intermediate-risk PE, LBMT had a significantly lower rate of the primary composite outcome including a lower rate of all-cause mortality when compared to AC alone. Ongoing randomized trials will test these associations.

Factors Predicting CT Pulmonary Angiography Results in the Emergency Department

Background: Pulmonary embolism (PE) remains a major concern in emergency patients presenting with respiratory symptoms, with an increase in the demand for CT pulmonary angiography (CTPA) and low yields of this ever more sensitive test. We wanted to investigate factors associated with pulmonary embolism on CTPA, aiming to reduce unnecessary requests. Methods: In a single-center, retrospective study, we analyzed all CTPA reports for emergency patients during the year 2023. Various patients' variables were evaluated for associations with the presence/absence of PE, including the presence or absence of pulmonary pathology identified prior to the CTPA order. Results: A total of 1555 CTPA reports were analyzed, of which 278 (17.9%) were positive for PE. The highest ORs (40.9) for PE were found for patients diagnosed with DVT prior to CTPA. The lowest odds ratios of having PE were found for patients with acute congestive heart failure (OR = 0.141), especially in the absence of cancer (OR = 0.089) and for patients with hypercapnia in COPD exacerbation (OR = 0.062). Tachycardia and hypoxemia were the physiological variables positively associated with PE, while hypercapnia was negatively associated with PE. For patients with heart failure, COPD exacerbation, and pneumonia, higher D-dimer cut-off values (3.87 mg/L, 1.25 mg/L, and 1.34 mg/L, respectively) were found to retain 100% sensitivity for PE. Conclusions: Stricter criteria for CTPA orders in the presence of other pulmonary pathologies may reduce unnecessary scanning. Higher D-dimer cut-off values in such cases may lead to higher specificity without sacrificing sensitivity.

Retrospective evaluation of the results of ultrasound-accelerated catheter-directed tombolysis in acute-subacute pulmonary embolism patients

ObjectivesAcute pulmonary embolism (PE) is one of the most serious forms of venous thromboembolism (VTE) with high mortality and morbidity. PE may present with right ventricular dysfunction and hemodynamic disturbances. Early diagnosis and appropriate treatment approaches play a critical role in improving survival. In this study, we evaluated the efficacy and safety of catheter-mediated thrombolytic therapy in intermediate-high-risk PE patients.MethodsOur retrospective study was conducted at Ankara University between 2015 and 2020 and 66 intermediate-high-risk PE patients were analyzed. Clinical, biochemical and echocardiographic data of the patients were analyzed and their response to treatment was evaluated. The primary endpoint was 30-day mortality and secondary endpoints were hemodynamic improvement, length of hospitalization and complication rates.ResultsThe mean age of the patients was 65 years and all of them presented with a diagnosis of symptomatic PE. After treatment, significant improvement was observed in right ventricular function, RV/LV ratio, ProBNP and Troponin I levels decreased significantly. Pulmonary artery pressures decreased and hemodynamic parameters improved. The early mortality rate after the procedure was 3% and the rate of major bleeding was low.ConclusionsCatheter-mediated thrombolytic therapy provides hemodynamic improvement in intermediate-high-risk PE patients, while offering a low bleeding risk. Our results suggest that this therapy may be a safe and effective alternative. However, long-term results should be evaluated in large-scale, randomized studies.

No Echo, no problem? Predictors of right heart strain among patients with pulmonary embolism

INTRODUCTION

Right heart strain (RHS) in pulmonary embolism (PE) is traditionally diagnosed with transthoracic echocardiography (TTE). Given limited access to TTE, clinicians use vital signs, laboratory markers, and computed tomography angiography (CTA) to estimate RHS. We investigate the association between these indicators and RHS on TTE among patients with PE.

METHODS

We reviewed charts of adult patients with PE transferred to a quaternary center from 2019 to 2022, excluding patients given thrombolytics before transfer. We collected vital signs and laboratory values at the time of transfer request and arrival. All CTAs were reinterpreted by a study radiologist. We used a hybrid Classification and Regression Tree - logistic regression to identify predictors of RHS on TTE.

RESULTS

We included 185 patients, 139 (75 %) with RHS on TTE. Patients with serum lactate <2 mmol/L with diastolic blood pressure (DBP) >63 mmHg at initial consult were 77 % less likely to have RHS (OR 0.23, 95 % CI 0.12-0.6, p < 0.001); those under 26 years with heart rate (HR) >90 bpm and lactate 2-8.5 mmol/L were 93.6 % less likely to have RHS (OR 0.064, 95 % CI 0.006-0.67, p = 0.022). Patients with higher HR at initial consult had higher rates of RHS (OR 1.01, 95 % CI 1.00.2-1.05, p = 0.03). Those with signs of RHS on CTA were 2.43 times more likely to have RHS (95 % CI 1.22-5.9, p = 0.014).

DISCUSSION

HR, lactate, DBP, and CTA findings of RHS were predictive of RHS on TTE among patients with PE. Clinicians should consider a collection of variables when assessing RHS in patients with PE when TTE is not available.

Pulmonary Vascular Interventions

Endovascular intervention is a safe, effective treatment modality in the management of diverse pulmonary vascular pathologies, including acute or chronic thromboembolic disease, pulmonary arteriovenous malformations (pAVMs), pulmonary artery or bronchial artery hemorrhage, and foreign body retrieval. This article reviews indications, contraindications, techniques, and outcomes in endovascular management of common pulmonary vascular pathologies, with the goal of improving operator familiarity and facility with these procedures.

Consent to advanced imaging in antenatal pulmonary embolism diagnostics: Prevalence, outcomes of nonconsent and opportunities to mitigate delayed diagnosis risk

BACKGROUND

Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.

METHODS

This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.

RESULTS

Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.

CONCLUSIONS

One in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.

Prognostic significance of diastolic wall strain as a predictor of remodeling and poor outcomes in heart failure and pulmonary embolism: A systematic review

BACKGROUND

Diastolic wall strain (DWS), also referred to as right ventricular (RV) dysfunction, is a significant predictor of pulmonary embolism (PE) and heart failure (HF). Rooted in linear elastic theory, DWS reflects decreased wall thinning during diastole, indicating reduced left ventricular (LV) compliance and increased diastolic stiffness. Elevated diastolic stiffness is associated with worse outcomes, particularly in PE and HF with preserved ejection fraction (HFpEF). This study systematically reviews the prognostic significance of DWS and its impact on PE and HF.

METHODS

A systematic search of scientific literature published between 2014 and 2024 was conducted using PubMed and Cochrane Reviews. Keywords such as "diastolic wall strain," "right ventricular dysfunction," and "pulmonary embolism" were employed to identify relevant studies. Seven articles meeting the inclusion criteria were selected and analyzed to synthesize insights into DWS and its role in risk stratification and prognosis for PE and HF patients.

RESULTS

The findings suggest that elevated DWS values are correlated with increased short- and long-term mortality in PE patients and a higher likelihood of early complications in both PE and HF. In cases where HF is present alongside elevated DWS, the risk of significant bleeding is heightened. DWS emerged as a reliable tool for PE risk stratification and predicting adverse outcomes in HF patients.

CONCLUSION

DWS is an essential prognostic marker for PE and HF, independently predicting major adverse cardiac events (MACE). Its straightforward assessment can improve risk stratification and guide clinical management in individuals at risk for cardiac failure.

Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism

BACKGROUND

The optimal management of patients with intermediate-risk pulmonary embolism (PE), who have right heart dysfunction (determined by a combination of imaging and cardiac biomarkers) but a normal blood pressure, is uncertain. These patients suffer from reduced functional capacity and a lower quality of life over the long-term, despite use of anticoagulant therapy. Catheter-directed therapy (CDT) is a promising treatment for acute PE that rapidly removes thrombus and potentially improves cardiac dysfunction. However, CDT has risk and is costly, and it is not known whether it improves long-term cardiorespiratory fitness and/or quality of life compared with anticoagulation alone.

METHODS

We are therefore conducting an open-label, assessor-blinded, multicenter randomized trial, the Pulmonary Embolism: Thrombus Removal with Catheter-Directed Therapy (PE-TRACT) Study, to compare CDT plus anticoagulation (CDT group) with anticoagulation alone (No-CDT group) in 500 patients with intermediate-risk PE. The primary study hypothesis is that CDT will increase the peak oxygen uptake (peak VO2) with cardiopulmonary exercise testing at 3 months and reduce New York Heart Association (NYHA) Class at 12 months compared with No-CDT. These 2 primary efficacy outcomes will be analyzed sequentially using a "gatekeeping" procedure; for NYHA class to be compared, peak oxygen consumption must first be shown to be significantly increased by CDT. Safety and cost-effectiveness will also be assessed.

CONCLUSION

When completed, PE-TRACT will provide important evidence regarding the benefits and risks of CDT to treat intermediate-risk PE compared with anticoagulation alone.

TRIAL REGISTRATION

clinicaltrials.gov: NCT05591118.

Tenecteplase Versus Alteplase: A Comparison of Bleeding Outcomes in Massive Pulmonary Embolism (TACO-PE)

BACKGROUND

Thrombolysis is recommended in the setting of massive pulmonary embolism (PE) for reperfusion of vessels but carries a serious concern for increased bleed risk. In October 2022, our institution adopted tenecteplase as the formulary thrombolytic. Previous literature is unclear regarding the bleed risk of tenecteplase in massive PE, and no study has yet compared safety outcomes with the current standard of care, alteplase.

OBJECTIVE

The objective of this study was to compare the incidence of bleeding with tenecteplase versus alteplase in massive PE patients.

METHODS

This was a retrospective, observational cohort study that included adults who received tenecteplase or alteplase for massive PE. The primary outcome was major bleeding as defined by the International Society on Thrombosis and Hemostasis (ISTH). Secondary outcomes included incidence of symptomatic intracranial hemorrhage (ICH), in-hospital mortality, administration of reversal agents, and length of stay.

RESULTS

A total of 44 patients met inclusion criteria with 20 patients in the alteplase cohort and 24 in the tenecteplase cohort. Seventeen percent of tenecteplase patients compared with 5% of alteplase patients experienced bleeding. The mortality rate was 83% vs 75%, respectively. In addition, 1 patient in the tenecteplase cohort experienced a symptomatic ICH and 2 patients required initiation of massive transfusion protocol.

CONCLUSION AND RELEVANCE

Although this study was limited in sample size, these results suggest that there may be reason for concern of higher bleeding rates in patients treated with tenecteplase in the setting of massive PE.

Fibrinolytic uses in the emergency department: a narrative review

INTRODUCTION

Several life-threatening conditions associated with thrombosis include acute ischemic stroke (AIS), acute myocardial infarction (AMI), and acute pulmonary embolism (PE). Fibrinolytics are among the treatment algorithms for these conditions.

OBJECTIVE

This narrative review provides emergency clinicians with an overview of fibrinolytics for AIS, AMI, and PE in the emergency department (ED) setting.

DISCUSSION

Pathologic thrombosis can result in vascular occlusion and embolism, ultimately leading to end-organ injury. Fibrinolytics are medications utilized to lyse a blood clot, improving vascular flow. One of the first agents utilized was streptokinase, though this is not as often used with the availability of fibrin-specific agents including alteplase (tPA), tenecteplase (TNK), and reteplase (rPA). These agents are integral components in the management of several conditions, including AIS, AMI, and PE. Patients with AIS who present within 3-4.5 h of measurable neurologic deficit with no evidence of intracerebral hemorrhage (ICH) or other contraindications may be eligible to receive tPA or TNK. In the absence of percutaneous coronary intervention (PCI), fibrinolytics should be considered in patients with AMI presenting with chest pain for at least 30 min but less than 12 h, though it may be considered up to 24 h. Unlike in AIS and PE, anticoagulation and antiplatelet medications should be administered in those with AMI receiving fibrinolytics. Following fibrinolytics, PCI is typically necessary. Fibrinolytics are recommended in patients with high-risk PE (hemodynamic instability), as they reduce the risk of mortality. The most significant complication following fibrinolytic administration includes major bleeding such as ICH, which occurs most frequently in those with AIS compared to AMI and PE. Thus, close patient monitoring is necessary following fibrinolytic administration.

CONCLUSIONS

An understanding of fibrinolytics in the ED setting is essential, including the indications, contraindications, and dosing.

The value of vector ECG in predicting residual pulmonary hypertension in CTEPH patients after pulmonary endarterectomy

INTRODUCTION

Right heart catheterization (RHC) is the diagnostic standard for establishing residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). A potential non-invasive alternative diagnostic test could be electrocardiography (ECG)-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO).

METHODS

We studied 66 CTEPH patients who underwent PEA. A subgroup of 20 patients also had a cardiac MRI before and after PEA. The diagnostic performance of the VG-RVPO for the detection of residual PH as well as the potential to replace RHC were assessed. Different cut-off values to define a normal VG-RVPO were evaluated. Also, we evaluated the association between mean pulmonary artery pressure (mPAP) and CMR derived indexed right ventricular (RV) mass and the VG-RVPO.

RESULTS

During follow-up, 28 patients had residual PH (42%). A decrease in VG-RVPO after PEA was associated with decrease in mPAP or indexed RV mass post PEA (r = 0.55, p < 0.05 and r = 0.64, p < 0.05, respectively). If a normal VG-RVPO would exclude residual PH, the need for RHC would be reduced with 15-48%, but up to 36% of the CTEPH patients with residual PH would have been missed as they had a normal VG-RVPO.

CONCLUSION

Although there was an association between the change in VG-RPVO and changes in mPAP or indexed RV mass, our study demonstrated that VG-RPVO has limited value in excluding the presence of residual PH post-PEA as up to 36% of the CTEPH patients with residual PH would have been missed if residual PH would have been excluded based on a normal VG-RVPO.

Complications of Pulmonary Embolism in a Pediatric Patient

A 16-year-old boy presents with a massive acute pulmonary embolism requiring emergent surgical embolectomy and extracorporeal membrane oxygenation for right ventricular failure. Subsequently he was diagnosed with catastrophic antiphospholipid syndrome requiring immunosuppression, and then pneumatoceles causing tension pneumothoraxes. The rarity of presentation in a child required collaboration across pediatric and adult disciplines.

The Incidence and Significance of Iliac Vein Stenosis in Patients with Deep Vein Thrombosis

BACKGROUND

The role of iliac vein stenosis (IVS) in the development of deep vein thrombosis (DVT) is poorly understood. This study determines the incidence of IVS in patients diagnosed with DVT and assesses its impact on presentation and outcomes. Our hypothesis is that the presence of IVS increases the risk of long-term ipsilateral DVT recurrence.

METHODS

A retrospective study of the electronic medical records of consecutive adult patients treated for lower extremity DVT was performed. Only patients with cross-sectional imaging (computed tomography or magnetic resonance with intravenous contrast) were included. Patient and DVT characteristics were recorded. Cross-sectional imaging was reviewed for the presence or absence of ipsilateral IVS (≥50%). Patients were divided into 2 groups based on the presence or absence of IVS to compare characteristics and outcomes. Subgroup analyses on patients with provoked DVT, cancer-related DVT, and unprovoked DVT were performed.

RESULTS

There were 548 patients with DVT and 32% had evidence of ipsilateral IVS on cross-sectional imaging. There were no significant differences in baseline characteristics or treatment methods between the 2 groups. There was a trend toward patients with IVS having less incidence of pulmonary embolism on presentation (22.9% vs. 29.7%, P = 0.1) but that difference did not reach statistical significance in the overall comparison. Subgroup analysis in patients with cancer-related DVT (n = 227) showed that patients with IVS were significantly more likely to develop ipsilateral recurrent DVT compared to patients with no IVS (12.9% vs. 4.5%, P = 0.045). Patients with unprovoked DVT with IVS had significantly lower pulmonary embolism on presentation than patients with unprovoked DVT without IVS (24.2% vs. 39.8%, P < 0.03).

CONCLUSIONS

Ipsilateral ≥50% IVS is present in approximately a third of patients presenting with DVT. The presence of IVS seems to play a differential role in ipsilateral DVT recurrence and prevention of pulmonary embolization in different groups of patients presenting with DVT.

Complications in interventional radiology: early detection and effective intervention strategies

This narrative review provides a comprehensive overview of complications in interventional radiology (IR), focusing on their aetiology, recognition, and management. As IR procedures continue to evolve and expand, understanding potential adverse events is crucial for improving patient safety and outcomes. The review will summarise various common complications associated with IR-based procedures, including their presentation, aetiology, and management. By consolidating current knowledge on these issues, the review offers valuable insights into minimising risks and enhancing procedural success. This synthesis will aid practitioners' knowledge and ultimately try and ensure safer IR practices and aftercare of patients.

The influence of patient sex on pulmonary embolism evaluation, treatment modality, and outcomes

BACKGROUND

Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality, accounting for 100,000 deaths per year in the United States. Although sex-based disparities have previously been described in this population, it is unclear if these differences have persisted with the expansion of PE evaluation and treatment approaches. The purpose of this study is to investigate sex-based differences in the evaluation, management, and outcomes of patients with acute PE.

METHODS

We performed a retrospective analysis of patients enrolled in the national Pulmonary Embolism Response Team (PERT) Consortium database between October 2015 and October 2022. We evaluated patient demographics, clinical characteristics, diagnostic imaging performed, treatment at several phases of care (pre-PERT, PERT recommendations, and post-PERT), and clinical outcomes.

RESULTS

A total of 5722 patients with acute PE (2838 [49.6%] women) from 35 centers were included. There were no differences in PE risk category between male and female patients. Women were less likely to undergo echocardiography (76.9% vs 73.8%) and more likely to receive no anticoagulation prior to PERT evaluation (35.5% vs 32.9%). PERT teams were more likely to recommend catheter-based interventions for men (26.6% vs 23.1%), and men were more likely to undergo these procedures (21.9% vs 19.3%). In a multivariable analysis, female sex was a predictor of in-hospital mortality (OR 1.53, 95% CI 1.06 to 2.21).

CONCLUSIONS

In this analysis, we identified sex-based differences in the evaluation and management of patients presenting with acute PE. Subsequently, women presenting with acute PE were at higher risk of in-hospital mortality.

Lower early mortality and risk prediction improvement of obesity after acute pulmonary embolism: results from a multicenter cohort analysis with external validation

Background

The relationship between obesity (defined as body mass index [BMI] ≥ 30 kg/m2) and mortality in venous thromboembolism remains controversial.

Objectives

We aimed to compare outcomes after pulmonary embolism (PE) between patients with obesity and nonobese, nonunderweight patients.

Methods

Using a multicenter registry of prospectively recorded individual patient data, we compared outcome rates using multivariable logistic or Cox regression for 30-day and 6-month outcomes respectively (etiologic analysis). We assessed the incremental value of adding BMI information on top of the 30-day European Society of Cardiology (ESC) prognostic algorithm (prognostic analysis).

Results

We included 2390 patients with BMI of ≥18.5 kg/m2 (mean age, 66.9 ± 16.8 years; 1188 men [49.7%]); 686 patients [28.7%] were in the obese group. Mortality rates were significantly lower in patients with obesity than that in patients who were nonobese at 30 days (3.2% [95% CI, 2.0-4.8] vs 5.9% [95% CI, 4.8-7.1]), and 6 months (8.1% [95% CI, 6.2-10.4] vs 16.3% [95% CI, 14.6-18.1]). Rates of secondary nonfatal outcomes (including bleeding, recurrent venous thromboembolism, myocardial infarction, and stroke) did not differ between groups. The addition of the obesity information on top of the ESC prognostic model improved global model fit and discriminatory (Harrell C index from 0.636 to 0.657; P = .07) and calibration capacities (P (Hosmer-Lemeshow) = .02 vs .13), yielding significant reclassification (ie, 10.3%) based on the observed mortality rates with the ESC model as reference. Findings were confirmed in an external validation using 35,796 patients with PE from the RIETE registry.

Conclusion

We present evidence indicating lower early- and mid-term mortality after PE in patients classified as obese based on BMI, compared with nonobese, nonunderweight patients. BMI should likely be incorporated into algorithms or scoring systems for predicting early mortality following PE.

Mechanical Thrombectomy for Acute Pulmonary Embolism in Non-Operating Room Anesthesia (NORA) Locations: Best Safety Practices and Local Insights

Mortality rates from pulmonary embolism (PE) remain significant, highlighting the need for alternative treatment strategies beyond traditional anticoagulation. Percutaneous interventions, including mechanical thrombectomy and catheter-directed thrombolysis, are emerging as promising options. Given the complex pathophysiology and unique risk profiles of these patients, meticulous multidisciplinary planning is essential. Anesthesiologists play a central role in coordinating care and managing perioperative risks to improve outcomes. This article provides insights into best safety practices and shares experiences from a leading quaternary center. It offers guidance for anesthesia providers to proactively engage in comprehensive risk stratification, participate in multidisciplinary discussions, and support robust contingency planning for managing PE patients undergoing percutaneous interventions in non-operating room anesthesia settings.

Catheter-directed therapy for pulmonary embolism in pediatrics: a systematic review and meta-analysis

BACKGROUND

Acute pulmonary embolism (PE) is a serious and potentially fatal condition that is relatively rare in the pediatric population. In patients presenting with massive/submassive PE, catheter-directed Therapy (CDT) presents an emerging therapeutic modality by which PE can be managed.

METHODS

Electronic databases were systematically searched through May 2024. This systematic review was performed in line with recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines and was registered in PROSPERO (Reg. no. CRD42024534229).

RESULTS

Sixteen case reports/series were included in the quantitative analysis with a total population of 40 children diagnosed with PE. Of them, 21 were females and 19 were males. Massive PE was diagnosed in 15 patients and submassive PE was diagnosed in 17 patients. Complete resolution of PE happened at a rate of 68% (95%CI = 46-80%). Mortality was encountered at a rate of 18% (95%CI = 0.7-36%). PE recurred after CDT at a rate of 15% (95%CI = 2-28%). Non-major bleeding complicated CDT at a rate of 46% (95%CI = 25-66%, p = 0.163).

CONCLUSION

CDT can be utilized in the management of PE in children as a potential therapeutic option for selected patients. While the results of CDT interventions for pediatric PE are promising, further research -including well-conducted cohort studies- is required to validate those results.

Preemptive anticoagulation during antenatal pulmonary embolism diagnostics in a community setting: retrospective cohort study

Background

Society recommendations for preemptive (or empiric) anticoagulation during antenatal pulmonary embolism (PE) diagnostics rely on expert opinion, which varies widely across guidelines. The American College of Chest Physicians (CHEST), for example, recommends preemptive anticoagulation when PE is highly suspected or when a delay in imaging is anticipated. The American College of Obstetricians and Gynecologists, however, makes no mention of preemptive anticoagulation for suspected PE in their practice bulletin on thromboembolism in pregnancy. Patterns of preemptive anticoagulation in pregnancy are unknown.

Objectives

To describe the prevalence of and CHEST-based eligibility for preemptive anticoagulation in pregnancy.

Methods

This retrospective cohort study was undertaken across 21 United States community hospitals from October 1, 2021 through March 30, 2023. We included pregnant adults without COVID-19 undergoing definitive diagnostic PE imaging. We used pregnancy-adapted Geneva scores to calculate pretest probability as a proxy for suspicion.

Results

We included 326 patients: median age, 31.0 years; 51% were in the third trimester. Diagnostic settings included emergency departments (n = 254; 78%), Labor & Delivery (n = 65; 20%), and outpatient clinics (n = 7; 2%). Median time from emergency department computed tomography order to results was 1.40 hours (IQR: 0.78, 2.06). Prevalence of confirmed or presumed PE was low (n = 8; 2.5%). Only 2 patients (0.6%) received preemptive anticoagulation, whereas by CHEST criteria, 34 patients (10.4%) were eligible.

Conclusion

We found rare use of preemptive anticoagulation during antenatal PE diagnostics in this imaged cohort with low PE prevalence and rapid access to diagnostic imaging. More research is needed to explore setting-specific variation in preemptive anticoagulation use.

Salvage pulmonary embolectomy following cardiac arrest: a 10-year experience

Introduction

Acute pulmonary embolism (PE), particularly massive PE, presents significant mortality risk, often necessitating emergency intervention such as surgical embolectomy. The prognosis for patients undergoing such interventions, especially after cardiac arrest, remains poor due to hemodynamic complications. This study aims to evaluate the efficacy of salvage pulmonary embolectomy in patients experiencing cardiac arrest due to massive PE, focusing on survival outcomes and influential risk factors.

Methods

Conducted at a single center over 10 years, this retrospective study involved 21 patients who underwent surgical embolectomy post-cardiac arrest due to massive PE. Data were collected on patient demographics, clinical presentation, and outcomes, analyzing factors such as age, hospital stay, and operative details.

Results

Out of 21 patients, 13 survived 1 year post-operation, translating to a 1-year survival rate of 61.90%. Intra-hospital survival was 76.19% (16 patients). Notable findings included a significant association between increased age and higher mortality (hazard ratio = 1.14, P = 0.024), and a longer hospital stay post-procedure in non-survivors (hazard ratio = 1.52, P = 0.03).

Conclusion

Salvage pulmonary embolectomy can improve survival in patients with massive PE following cardiac arrest. However, outcomes heavily depend on the patient's age and the length of the hospital stay. Future studies should focus on refining surgical techniques and improving pre- and postoperative care to enhance survival rates further.

A Comprehensive Clinical Acumen Enhanced by Point-of-Care Ultrasonography in Managing Acute Life-Threatening Massive Pulmonary Thromboembolism in a Peripheral Setting: A Case Report

ABSTRACT

Acute massive pulmonary thromboembolism (PTE) is a potentially life-threatening condition requiring urgent management to decrease mortality. However, in the peripheral setting, managing the emergency can be challenging. We report a case of massive PTE presenting with cardiopulmonary arrest, successfully managed with advanced cardiac life support, early initiation of anticoagulants (heparin), and thrombolytics. This case report explores the successful management of a critically ill patient presenting with massive pulmonary embolism in a peripheral healthcare facility, emphasizing the importance of a well-coordinated approach in such challenging environments. The approach in the case included recognizing the challenge with timely provisional diagnosis, initial stabilization, hemodynamic support, early consideration for anticoagulants, and thrombolysis after supporting provisional diagnosis with point-of-care ultrasonography (POCUS), team effort, and administrative support in Cas Evac to the tertiary care center. Timely administration of heparin and thrombolytics may serve as potential life-saving measures in peripheral settings, along with the availability of an ultrasound machine. Managing acute life-threatening massive PTE in peripheral settings requires a strategic and resourceful approach. Timely administration of heparin and thrombolytics may serve as potential life-saving measures. However, the administration of thrombolytics in PTE needs the support of POCUS to make quick decisions in peripheral settings. Collaboration between peripheral and advanced tertiary care healthcare facilities is crucial to ensure optimal outcomes for patients experiencing this critical condition.

Impact of Vein Wall Hyperelasticity and Blood Flow Turbulence on Hemodynamic Parameters in the Inferior Vena Cava with a Filter

Inferior vena cava (IVC) filters are vital in preventing pulmonary embolism (PE) by trapping large blood clots, especially in patients unsuitable for anticoagulation. In this study, the accuracy of two common simplifying assumptions in numerical studies of IVC filters-the rigid wall assumption and the laminar flow model-is examined, contrasting them with more realistic hyperelastic wall and turbulent flow models. Using fluid-structure interaction (FSI) and computational fluid dynamics (CFD) techniques, the investigation focuses on three hemodynamic parameters: time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), and relative residence time (RRT). Simulations are conducted with varying sizes of clots captured in the filter. The findings show that, in regions of high wall shear stress, the rigid wall model predicted higher TAWSS values, suggesting an increased disease risk compared to the hyperelastic model. However, the laminar and turbulent flow models did not show significant differences in TAWSS predictions. Conversely, in areas of low wall shear stress, the rigid wall model indicated lower OSI and RRT, hinting at a reduced risk compared to the hyperelastic model, with this discrepancy being more evident with larger clots. While the predictions for OSI and TAWSS were closely aligned for both laminar and turbulent flows, divergences in RRT predictions became apparent, especially in scenarios with very large clots.

Prolonged elevated heart rate is association with adverse outcome in severe pulmonary embolism: A retrospective study

BACKGROUND

Pulmonary embolism (PE) is a critical condition characterized by the obstruction of pulmonary arteries by thrombi, which significantly contributes to morbidity and mortality globally. Although prolonged elevated heart rate (peHR) is recognized as a risk factor for adverse outcomes in critically ill patients, its specific impact on severe PE has remained unexplored.

METHODS

This retrospective cohort study analyzed data from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients diagnosed with PE were included in the study. peHR was defined as heart rates exceeding 100 beats per minute on at least 11 occasions within any 12-h interval. Cox proportional hazards regression models were used to evaluate the impact of peHR on 30-day and 90-day mortality rates, adjusting for a broad range of demographic and clinical variables.

RESULTS

A total of 1248 patients were included in this study, of whom 540 exhibited peHR. These patients experienced significantly longer hospital and intensive care unit (ICU) stays, as well as higher mortality rates at both 30 days (25.93 % vs. 14.97 %, P < 0.001) and 90 days (33.89 % vs. 22.74 %, P < 0.001) compared to patients without peHR. Multivariate Cox regression analysis confirmed peHR as an independent predictor of increased mortality at 30 days (HR 1.56, 95 % CI 1.19-2.07; P = 0.0014) and 90 days (HR 1.66, 95 % CI 1.32-2.10; P < 0.001).

CONCLUSION

peHR significantly worsens outcomes in severe PE patients, underscoring the need for stringent heart rate monitoring and management. These findings advocate for integrating heart rate control within management strategies for severe PE, potentially improving survival outcomes.

A Practical Clinical Approach to Navigate Pulmonary Embolism Management: A Primer and Narrative Review of the Evolving Landscape

Advances in imaging, pharmacological, and procedural technologies have rapidly expanded the care of pulmonary embolism. Earlier, more accurate identification and quantification has enhanced risk stratification across the spectrum of the disease process, with a number of clinical tools available to prognosticate outcomes and guide treatment. Direct oral anticoagulants have enabled a consistent and more convenient long-term therapeutic option, with a greater shift toward outpatient treatment for a select group of low-risk patients. The array of catheter-directed therapies now available has contributed to a more versatile and nuanced armamentarium of treatment options, including ultrasound-facilitated thrombolysis and mechanical thrombectomy. Research into supportive care for pulmonary embolism have explored the optimal use of vasopressors and volume resuscitation, as well as utilization of various devices, including right ventricular mechanical support and extracorporeal membrane oxygenation. Even in the realm of surgery, outcomes have steadily improved in experienced centers. This rapid expansion in diagnostic and therapeutic data has necessitated implementation of pulmonary embolism response teams to better interpret the available evidence, manage the utilization of advanced therapies, and coordinate multidisciplinary care. We provide a narrative review of the risk stratification and management of pulmonary embolism, with a focus on structuralizing the multidisciplinary approach and organizing the literature on new and emerging therapies.

Pulmonary Embolism Response Teams-Evidence of Benefits? A Systematic Review and Meta-Analysis

Background: Venous thromboembolisms constitute a major cause of morbidity and mortality with 60,000 to 100,000 deaths attributed to pulmonary embolism in the US annually. Both clinical presentations and treatment strategies can vary greatly, and the selection of an appropriate therapeutic strategy is often provider specific. A pulmonary embolism response team (PERT) offers a multidisciplinary approach to clinical decision making and the management of high-risk pulmonary emboli. There is insufficient data on the effect of PERT programs on clinical outcomes. Methods: We searched PubMed, Scopus, Web of Science, and Cochrane to identify PERT studies through March 2024. The primary outcome was all-cause mortality, and the secondary outcomes included the rates of surgical thrombectomy, catheter directed thrombolysis, hospital length of stay (HLOS), and ICU length of stay (ICULOS). We used the Newcastle-Ottawa Scale tool to assess studies' quality. We used random-effects models to compare outcomes between the pooled populations and moderator analysis to identify sources of heterogeneity and perform subgroup analysis. Results: We included 13 observational studies, which comprised a total of 12,586 patients, 7512 (60%) patients were from the pre-PERT period and 5065 (40%) patients were from the PERT period. Twelve studies reported the rate of all-cause mortality for their patient population. Patients in the PERT period were associated with similar odds of all-cause mortality as patients in the pre-PERT period (OR: 1.52; 95% CI: 0.80-2.89; p = 0.20). In the random-effects meta-analysis, there was no significant difference in ICULOS between PERT and pre-PERT patients (difference in means: 0.08; 95% CI: -0.32 to 0.49; p = 0.68). There was no statistically significant difference in HLOS between the two groups (difference in means: -0.82; 95% CI: -2.86 to 1.23; p = 0.43). Conclusions: This meta-analysis demonstrates no significant difference in all studied measures in the pre- and post-PERT time periods, which notably included patient mortality and length of stay. Further study into the details of the PERT system at institutions reporting mortality benefits may reveal practice differences that explain the outcome discrepancy and could help optimize PERT implementation at other institutions.

Large uterine fibroid causing DVT and PE: Successful management with mechanical aspiration thrombectomy and hysterectomy: A case report and literature review

RATIONALE

Uterine leiomyomas, though commonly benign, can occasionally lead to serious complications, including deep vein thrombosis (DVT) and pulmonary embolism (PE). This study aims to highlight the uncommon yet serious association between large uterine leiomyomas and thromboembolism, which is often overlooked in patients without traditional risk factors. It emphasizes the need for awareness, early diagnosis, and timely intervention to prevent complications in patients presenting with unexplained symptoms and pelvic masses.

PATIENT CONCERN

A 38-year-old gravida 5, para 2 woman presented to the emergency room with left lower extremity swelling, pain, and discoloration, accompanied by dyspnea. She had no prior history of DVT or PE and did not have any known risk factors for venous thromboembolism.

DIAGNOSIS

The patient was diagnosed with DVT and PE, confirmed by venous duplex ultrasound and abdominal and pelvic computed tomography, which revealed thrombus extension to the left iliac vein. Chest computed tomography angiography confirmed a partially occlusive thrombus in the pulmonary arteries.

INTERVENTION

The patient underwent mechanical aspiration thrombectomy, followed by placement of a left iliac stent. Anticoagulation therapy with heparin was initiated post-thrombectomy. On the third day, a right supracervical hysterectomy was successfully performed. After surgery, anticoagulation was continued with heparin, and the patient was later discharged on apixaban for ongoing therapy.

OUTCOMES

The patient made full recovery with no recurrence of thromboembolic events at 11 months posttreatment.

LESSONS

This case highlights the rare but serious complication of DVT and PE in patients with uterine leiomyomas. Timely intervention with thrombectomy, stent placement, and hysterectomy was effective in resolving the thromboembolic events.

Management Strategies for Acute Pulmonary Embolism in the ICU

TOPIC IMPORTANCE

Acute pulmonary embolism (PE) is a common disease encountered by pulmonologists, cardiologists, and critical care physicians throughout the world. For patients with high-risk acute PE (defined by systemic hypotension) and intermediate high-risk acute PE (defined by the absence of systemic hypotension, but the presence of numerous other concerning clinical and imaging features), intensive care often is necessary. Initial management strategies should focus on optimization of right ventricle (RV) function while decisions about advanced interventions are being considered.

REVIEW FINDINGS

We reviewed the existing literature of various vasoactive agents, IV fluids and diuretics, and pulmonary vasodilators in both animal models and human trials of acute PE. We also reviewed the potential complications of endotracheal intubation and positive pressure ventilation in acute PE. Finally, we reviewed the data of venoarterial extracorporeal membrane oxygenation use in acute PE. The above interventions are discussed in the context of the underlying pathophysiologic features of acute RV failure in acute PE with corresponding illustrations.

SUMMARY

Norepinephrine is a reasonable first choice for hemodynamic support with vasopressin as an adjunct. IV loop diuretics may be useful if evidence of RV dysfunction or volume overload is present. Fluids should be given only if concern exists for hypovolemia and absence of RV dilatation. Supplemental oxygen administration should be considered even without hypoxemia. Positive pressure ventilation should be avoided if possible. Venoarterial extracorporeal membrane oxygenation cannulation should be implemented early if ongoing deterioration occurs despite these interventions.

Inferior Vena Cava Filters: Adherence to Clinical Practice Guidelines Recommendations, Retrieval Rates, and Filter Complications in a Tertiary Hospital

The present study evaluated the adherence to guideline recommendations regarding the indication for inferior vena cava filter (IVCF) placement, retrieval rates, complications, thrombotic recurrences, and mortality. Patients in whom an IVCF was placed between 2015 and 2020 in a tertiary hospital were retrospectively included. We considered absolute indication of IVCF placement if all the guidelines evaluated agreed on the indication, relative indication if only some guidelines recommended it and without indication if none of the evaluated guidelines recommended it. From the 185 patients included; 47% had an absolute indication, 15% a relative indication, and 38% had no indication. Filter-associated complications and non-removal rates were 12.4% and 41%, respectively. Venous thromboembolism recurrence rate was 17.8%, being filter-associated complications (24.2 vs 9.8%, P = .02) and thrombosis of the inferior cava or iliac veins (12.1 vs 2.6%, P = .03) more frequent in this group. The mortality rate was 40%, with higher mortality risk in patients with co-existing cancer. Previous major bleeding, filter-associated complications, and mortality were associated with a major risk of non-removal. In conclusion, the adherence to guidelines regarding the indication of IVCF placement is still low and IVCF complications are not negligible. This fact is of special concern in the elderly, comorbid, and cancer patients.

Acute Pulmonary Embolism: Evidence, Innovation, and Horizons

PURPOSE OF REVIEW

Pulmonary embolism (PE) is the third most common cause of cardiovascular morbidity and mortality. The goal of this review is to discuss the most up-to-date literature on epidemiology, diagnosis, risk stratification, and management of acute PE.

RECENT FINDINGS

Despite an increase in annual incidence rate of PE in the United States and development of multiple advanced therapies for treatment of acute PE, PE-related mortality is not consistently decreasing across populations. Although multiple risk stratification schemes have been developed, it is still unclear which advanced therapy should be used for the individual patient and optimal timing. Fortunately, multiple randomized clinical trials are underway to answer these questions. Nevertheless, up to 50% of patients have persistent reduced quality of life 6 months after acute PE, termed post-PE syndrome. Despite advances in therapeutic options for management of acute PE, many questions remain unanswered, including optimal risk stratification and management of acute PE.

Long-Term Echocardiographic and Clinical Outcomes After Invasive and Non-Invasive Therapies for Sub-Massive and Massive Acute Pulmonary Embolism

AIM

Acute pulmonary embolism (PE) is a significant cause of mortality in the hospital setting. The objective of this study was to outline the long-term outcomes after surgical and non-surgical management for patients with massive and submassive PE.

METHODS

Population cohort observational study evaluating all patients who presented to three tertiary hospitals in the state of Western Australia with access to cardiothoracic services over 5 years (2013-2018). Reviewed notes of all patients as well as radiology, linked mortality data and all available echocardiography studies at the primary hospital.

RESULTS

In total, 245 patients were identified, of which 41 received surgical management and 204 non-surgical management; demographic data was similar. Clinically, the surgical group had higher rates of shock requiring vasopressors, severe bradycardia, or cardiopulmonary resuscitation prior to intervention. The 28-day mortality was not statistically significantly different between the surgical embolectomy group (2/41 [4.2%]) and the non-surgical group (17/201 [8.3%]) (p=0.382). There was no difference in 12-month mortality, including when this was adjusted for vasopressors, right ventricular (RV) strain, troponin, and brain natriuretic peptide. In the massive PE sub-group, 28-day mortality was not significantly different: 2/29 (6.9%) surgical group vs 7/34 (20.2%) non-surgical group (p=0.064). Higher rates of severe RV impairment and dilatation were present in the surgical group. All patients with available echocardiography studies at outpatient follow-up returned to normal or mild RV impairment.

CONCLUSION

Patients who presented with massive or submassive PE had similar outcomes whether treated with surgical or non-surgical management. Surgical embolectomy is a safe option in a cardiothoracic centre setting.

Pregnancy-associated pulmonary embolism (PA-PE): catheter-directed thrombolysis as first-line rescue

Pregnancy-associated pulmonary embolism (PA-PE) is a life-threatening presentation however literature surrounding its optimal management is limited. This case describes a case of PA-PE treated with catheter-directed thrombolysis after clinical deterioration despite standard anticoagulation therapy. Careful multidisciplinary planning is required to successfully manage the deteriorating patient with PA-PE with catheter-directed thrombolysis being considered as potential first-line therapy in these patients.

International Clinical Practice Guideline Recommendations for Acute Pulmonary Embolism: Harmony, Dissonance, and Silence

Despite abundant clinical innovation and burgeoning scientific investigation, pulmonary embolism (PE) has continued to pose a diagnostic and management challenge worldwide. Aging populations, patients living with a mounting number of chronic medical conditions, particularly cancer, and increasingly prevalent health care disparities herald a growing burden of PE. In the meantime, navigating expanding strategies for immediate and long-term anticoagulation, as well as advanced therapies, including catheter-based interventions for patients with more severe PE, has become progressively daunting. Accordingly, clinicians frequently turn to evidence-based clinical practice guidelines for diagnostic and management recommendations. However, numerous international guidelines, heterogeneity in recommendations, as well as areas of uncertainty or omission may leave the readers and clinicians without a clear management pathway. In this review of international PE guidelines, we highlight key areas of consistency, difference, and lack of recommendations (silence) with an emphasis on critical clinical and research needs.

Innovation in Catheter-Directed Therapy for Intermediate-High-Risk and High-Risk Pulmonary Embolism

Although anticoagulation remains the cornerstone treatment for patients with acute pulmonary embolism (PE), catheter-directed therapy (CDT) has generated great interest as an adjunctive option for those presenting with hemodynamic decompensation or high risk for deterioration and in whom systemic thrombolysis has failed or is contraindicated. However, randomized controlled data supporting the efficacy and safety of CDT in addition to antithrombotic therapy in patients with high-risk and intermediate- to high-risk PE compared with anticoagulation and systemic thrombolysis alone are lacking. This paucity of high-quality data hampers guideline recommendations regarding the optimal therapeutic approach in such patients with PE. The aim of the present paper is to critically appraise the current evidence for CDT in patients with high-risk and intermediate- to high-risk PE and to highlight major areas of innovation in the recent literature. In addition, the authors describe unmet clinical and research needs, potential strategies to resolve these knowledge gaps, and pathways for device selection.

Pulmonary Embolism Management Audit and Machine Learning Analysis of Delayed Anticoagulation in a Swiss Teaching Hospital

Background/Objectives: Diagnosing acute pulmonary embolism (PE) is challenging due to its wide range of symptoms and numerous differential diagnoses. Medical professionals must balance performing all essential examinations and avoiding unnecessary testing. This study aimed to retrospectively audit the diagnosis and treatment of acute PE at a Swiss public teaching hospital to determine the adherence to current guidelines and to identify the factors associated with the delayed initiation of anticoagulation in PE patients. Methods: In this retrospective observational cohort study, we included all adult patients hospitalized with PE at the Cantonal Hospital Baselland (KSBL) between November 2018 and October 2020, where the diagnosis was made within the first twelve hours of their arrival to the emergency department (ED). LASSO regression was employed to identify clinical characteristics associated with delayed anticoagulation initiation. Results: A total of 197 patients were included (mean age: 70 years, 54% female). The audit revealed that diagnostic workup was conducted according to guidelines in 57% of cases. Often, D-dimer levels were measured although not strictly necessary (70%). Pretest probability was assessed and documented using the Wells or Geneva score in only 3% of patients, and risk assessment via the Pulmonary Embolism Severity Index (PESI) score was documented in 21% of patients. The median time from ED arrival to CT scan was 120 min (IQR 89.5-210.5), and the median time to anticoagulation initiation was 193 min (IQR 145-277). Factors identified by LASSO associated with delayed anticoagulation included prolonged time from ED arrival to CT scan, the presence of distended jugular veins on examination, ED arrival in the morning, and presenting symptoms of weakness or tiredness. Complementary leg ultrasound was performed in 57% of patients, with 38% of these cases lacking prior clinical examination for deep vein thrombosis. The duration of the anticoagulation treatment was not specified in the discharge report for 17% of patients. A medical follow-up after discharge was recommended in 75% of the patients. Conclusions: In conclusion, while the management of PE at the KSBL generally adheres to high standards, there are areas for improvement, particularly in the morning performance, the use of a pretest probability assessment, D-dimer measurement, risk assessment via the PESI score, the performance of complementary leg ultrasounds, clarification of the anticoagulation duration, and follow-up management.

Thrombus vs Tumor: Use of AngioVac in a RV Mass

This paper present a challenging case of a right ventricular mass in a patient who was at high surgical risk for open removal. The minimally invasive AngioVac device has been used with a successful 50% reduction in mass burden. This report illustrates AngioVac as a safe alternative to invasive surgery.