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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Ho P, Al-Chami F, Caroline M, Gnall E, Bonn J, Greenspon L. Paradoxical pulmonary artery systolic pressure response with catheter-directed therapies for pulmonary embolism. Am Heart J Plus 2023; 34:100320. [PMID: 38510955 PMCID: PMC10946050 DOI: 10.1016/j.ahjo.2023.100320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 03/22/2024]
Abstract
Background Early data on use of catheter-directed therapies (CDT) for treatment of Intermediate or High-Risk pulmonary embolism (PE) show improvement in pulmonary artery systolic pressures (PAsP) and RV/LV ratios. Occasionally a paradoxical rise in PAsP was observed with CDT utilizing ultrasound-assisted thrombolysis (USAT). It is unclear whether this pattern is seen with CDT utilizing mechanical aspiration. Objectives To investigate and compare the changes in PAsP between those who underwent CDT with USAT to those with mechanical aspiration. Methods A retrospective analysis of those diagnosed with Intermediate or High-Risk PE who underwent CDT using USAT or mechanical aspiration from 7/2013 to 3/2023. The primary outcome was comparison of PAsP changes between the two modalities. Secondary outcomes include length of stay, mortality, and bleeding complications. Results A total of 142 patients were analyzed, of which 93 underwent USAT and 49 underwent mechanical thrombectomy. The mechanical thrombectomy group had significantly lower post-intervention PAsP than the USAT group (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.5 ± 2.7 vs. -7.7 ± 3.2 mmHg. p < 0.0001). A higher frequency of a paradoxical rise in PAsP was observed in the USAT group (22 % vs 4.1 %, p < 0.001). Conclusions CDT utilizing mechanical thrombectomy was associated with lower post-interventional PAsP and greater mean negative change compared to USAT. Occasional paradoxical rises in PAsP were observed with both types of CDT, but they were more frequent with USAT. Hemodynamic monitoring should be considered after CDT. Condensed unstructured abstract We report a retrospective comparison of changes to pulmonary artery systolic pressures (PAsPs) between catheter-directed ultrasound-assisted thrombolysis (USAT) and catheter-directed mechanical thrombectomy in Intermediate and High-Risk pulmonary embolism. Those treated with mechanical thrombectomy compared to USAT had significantly lower post-interventional PAsP (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.2 ± 2.7 vs. -7.5 ± 3.2 mmHg, p < 0.0001). A paradoxical rise in PAsP was observed more frequently in the USAT group than the mechanical thrombectomy group (22 % vs 4.1 %, p < 0.001).
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Affiliation(s)
- Patrick Ho
- Division of Pulmonary & Critical Care Medicine, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Farouk Al-Chami
- Division of Internal Medicine, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Mara Caroline
- Division of Interventional Cardiology, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Eric Gnall
- Division of Interventional Cardiology, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Joseph Bonn
- Division of Interventional Radiology, Lankenau Medical Center, Wynnewood, PA, United States of America
| | - Lee Greenspon
- Division of Pulmonary & Critical Care Medicine, Lankenau Medical Center, Wynnewood, PA, United States of America
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Benfor B, Haddad P, Bohle K, Atkins MD, Lumsden AB, Peden EK. Cardiovascular collapse during mechanical thrombectomy for acute pulmonary embolism and the role of extracorporeal membrane oxygenation in patient rescue. J Vasc Surg Venous Lymphat Disord 2023; 11:978-985.e3. [PMID: 37030443 DOI: 10.1016/j.jvsv.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Driven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of intermediate-to-high risk pulmonary embolism (PE). This study investigated the incidence and outcomes of cardiovascular collapse during MT procedures and demonstrates the role of extracorporeal membrane oxygenation (ECMO) in salvaging patients. METHODS This single-center retrospective review included patients with PE undergoing MT with the FlowTriever device between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated. RESULTS A total of 151 patients with a mean age of 64 ± 14 years who presented with intermediate-to-high risk PE received LBAT procedures during the study period. The simplified PE severity score was ≥1 in 83% of cases and the average RV/LV ratio was 1.6 ± 0.5, with and elevated troponin in 84%. Technical success was achieved in 98.7% and a significant decrease in pulmonary artery systolic pressure (PASP) was observed (37 mm Hg vs 56 mm Hg; P < .0001). Intraoperative cardiac arrest occurred in nine patients (6%). These patients were more likely to present PASP of ≥70 mm Hg (84% vs 14%; P < .001), were more hypotensive upon admission (systolic of 94 ± 14 mm Hg vs 119 ± 23 mm Hg; P = .004), presented lower oxygen saturation levels (87 ± 6% vs 92 ± 6%; P = .023) and were more likely to present with a history of recent surgery (67% vs 18%; P = .004). Four patients were rescued successfully with ECMO and their residual PE was subsequently removed before discharge by surgical embolectomy in two of the four cases and repeat MT in the other two. All five patients (3%) who did not receive ECMO support expired intraoperatively. The overall 30-day mortality was 8% with no death occurring in patients who were salvaged with ECMO. CONCLUSIONS Large-bore aspiration thrombectomy for acute PE is associated with favorable technical outcomes, but the concern for acute cardiac decompensation is non-negligible in patients presenting with high-risk features and a PASP of ≥70 mm Hg. ECMO can help to salvage some of these patients and should be considered in the treatment algorithms of patients deemed at high risk.
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Affiliation(s)
- Bright Benfor
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Paul Haddad
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Kihoon Bohle
- School of Engineering Medicine, Texas A&M University, Houston, TX
| | - Marvin D Atkins
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Alan B Lumsden
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Eric K Peden
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX.
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Semaan DB, Phillips AR, Reitz K, Sridharan N, Mulukutla S, Avgerinos E, Eslami MH, Chaer R. Improved long-term outcomes with catheter-directed therapies over medical management in patients with submassive pulmonary embolism-a retrospective matched cohort study. J Vasc Surg Venous Lymphat Disord 2023; 11:70-81. [PMID: 36210021 DOI: 10.1016/j.jvsv.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The benefit of catheter-directed therapy (CDT) for submassive pulmonary embolism (sPE) has been the subject of debate. We sought to determine the short- and long-term mortality and outcomes of CDT compared with anticoagulation for patients with sPE. METHODS We performed a single healthcare network, multihospital, retrospective cohort study of hospitalizations for sPE from 2012 to 2019. sPE was defined as the presence of right heart strain or elevated biomarkers (troponin I or B-type natriuretic peptide). Patients with massive PE and those who had undergone systemic thrombolysis were excluded. The sPE groups included therapeutic anticoagulation alone or anticoagulation plus CDT (ie, thrombolysis or suction thrombectomy). The primary outcome was mortality at 1, 3, and 5 years. The other measured outcomes included PE-related death, short term mortality (30 days and 3 and 6 months), 30-day treatment-related complications (eg, bleeding, transfusion, stroke), chronic thromboembolic pulmonary hypertension, and 6-minute walk test at 1 year. After 1:1 nearest-neighbor propensity score matching, Kaplan-Meier survival plots were generated, and the treatment groups were compared using log-rank testing. We used Cox multivariate analysis to evaluate the outcomes after clustering at the hospital level, generating matched hazard ratios (mHRs) with associated 95% confidence intervals (CIs). RESULTS Of 6746 sPE hospitalizations, the patients who had received CDT were younger (age, 58.9 ± 15.5 years vs 61.5 ± 17.4 years; P = .004), were more frequently White (92.5% vs 85.7%; P < .001), and had presented with a higher mean heart rate (104.6 bpm vs 94.9 bpm; P < .001), lower median systolic blood pressure (129 mm Hg vs 135 mm Hg; P < .001), and a greater incidence of right heart strain (79.2% vs 20.3%; P < .001). A total of 470 patients were matched, with 235 in the CDT group and 235 in the anticoagulation-only group. CDT was associated with a lower risk of mortality compared with anticoagulation at 1 year (7.6% vs 9.8%; mHR, 0.77; 95% CI, 0.65-0.92; P = .004), 3 years (11.1% vs 16.6%; mHR, 0.64; 95% CI, 0.55-0.73; P < .001), and 5 years (14.5% vs 19.1%; mHR, 0.71; 95% CI, 0.66-0.77; P < .001). Anticoagulation alone resulted in a greater incidence of PE-related deaths at 1, 3, and 5 years. The mortality at 30 days and 3 months was similar; however, CDT had resulted in better survival at 6 months (mHR, 0.81; 95% CI, 0.68-0.97; P = .02). No differences were found between the two groups in the incidence of bleeding complications at 30 days, development of chronic thromboembolic pulmonary hypertension, or the mean walking distance at 1 year. CONCLUSIONS CDT plus anticoagulation for sPE was associated with improved long-term survival compared with anticoagulation alone, with a lower incidence of PE-related death and a low complication rate. CDT should be considered for select patients with sPE given its survival benefit.
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Hassan AKM, Ahmed H, Ahmed Y, Elfadl AEA, Omar A. Efficacy and safety of hydro-mechanical defragmentation in intermediate- and high-risk pulmonary embolism. Egypt Heart J 2021; 73:84. [PMID: 34564780 PMCID: PMC8464550 DOI: 10.1186/s43044-021-00204-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 11/22/2022] Open
Abstract
Background Pulmonary embolism (PE) is the third most common acute cardiovascular syndrome. Percutaneous catheter directed hydro-mechanical defragmentation (HMD) is one of the recommended treatment options for PE in patients with contraindications to thrombolytic therapy or failed systemic thrombolysis (ST). We aimed to identify the safety and outcomes of catheter directed HMD in patients with high-risk PE. This nonrandomized controlled trial enrolled all patients with confirmed diagnoses of high- and intermediate-high-risk PE from October 2019 till January 2021. Fifty patients were included and divided into two groups by the PE response team according to the presence or absence of a contraindication for ST. Group B (ST) consists of 25 patients and group A (HMD) of 25 patients who cannot receive ST. Results The two groups were comparable regarding baseline clinical characteristics with mean age 51 ± 13 years. In group A, systolic blood pressure (BP) and oxygen saturation increased after 24 h (p = 0.002) and 48 h (p < 0.001) compared to pre-HMD procedure. Mean pulmonary artery systolic pressure (PASP) and respiratory rate (RR) decreased after 48 h and at 30 days (p < 0.001) compared to pre-HMD procedure. The increase in systolic BP and oxygen saturation were significantly higher in HMD group compared with ST group after 48 h and at 30 days (p < 0.007). The decrease in PASP and RR was significantly higher in HMD group compared to ST group after 48 h and at 30 days (p < 0.001). Mortality rate at 30 days was 20% in HMD group compared to 32% in ST group. Conclusions Catheter directed HMD for high-risk and intermediate-high-risk PE is safe and effective with acceptable mortality Trial registration Clinical trial ID: NCT04099186.
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Affiliation(s)
- Ayman K M Hassan
- Cardiology Department, Assiut University, P.Box: 71526, Asyut, Egypt.
| | - Heba Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | - Yousef Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | | | - Amany Omar
- Chest Department, Assiut University, Asyut, Egypt
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Delmas C, Aissaoui N, Meneveau N, Bouvaist H, Rousseau H, Puymirat E, Sapoval M, Flecher E, Meyer G, Sanchez O, Del Giudice C, Roubille F, Bonello L. Reperfusion therapies in pulmonary embolism-state of the art and expert opinion: A position paper from the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology. Arch Cardiovasc Dis 2020; 113:749-759. [PMID: 32978090 DOI: 10.1016/j.acvd.2020.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 01/21/2023]
Abstract
Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Inserm UMR 1048, Institute of Metabolic and Cardiovascular Diseases (I2MC), 31432 Toulouse, France
| | - Nadia Aissaoui
- Critical Care Unit, Penn State Heart and Vascular Institute (HVI), Hershey Medical Center (HMC) and Penn State University, 17033 PA, USA; Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen George Pompidou, AP-HP, 75015 Paris, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, 25000 Besancon, France
| | - Helene Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Hervé Rousseau
- Department of Radiology, Hôpital Rangueil 1, CHU de Toulouse, 31059 Toulouse, France
| | - Etienne Puymirat
- Intensive Cardiac Care Unit, Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Marc Sapoval
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Inserm UMR 1099, 35000 Rennes, France
| | - Guy Meyer
- Department of Pneumology, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris and CIC 1418, 75015 Paris, France
| | - Olivier Sanchez
- Department of Pulmonology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Inserm UMRS 1140, Université de Paris, 75270 Paris, France
| | - Costantino Del Giudice
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - François Roubille
- Department of Cardiology, CHU de Montpellier, Université de Montpellier, Inserm, CNRS, 34295 Montpellier, France
| | - Laurent Bonello
- Intensive Care Unit, Department of Cardiology, Hôpital Nord, AP-HM, Aix-Marseille Université, 13015 Marseille; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13000 Marseille, France; INSERM 1263, 1260, Centre for Cardiovascular and Nutrition Research (C2VN), INRA, 13385 Marseille, France.
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Ruohoniemi DM, Sista AK. Interventional Radiology Therapy: Inferior Vena Cava Filter and Catheter-based Therapies. Crit Care Clin 2020; 36:481-95. [PMID: 32473693 DOI: 10.1016/j.ccc.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Endovascular management of pulmonary embolism can be divided into therapeutic and prophylactic treatments. Prophylactic treatment includes inferior vena cava filter placement, whereas endovascular therapeutic interventions include an array of catheter-directed therapies. The indications for both modalities have evolved over the last decade as new evidence has become available.
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Abstract
Anticoagulation is the cornerstone of acute pulmonary embolism (PE) therapy. Intermediate-risk (submassive) or high-risk (massive) PE patients have higher mortality than low-risk patients. It is generally accepted that high-risk PE patients should be considered for more aggressive therapy. Intermediate-risk patients can be subdivided, although more than simply categorizing the patient is required to guide therapy. Therapeutic approaches depend on a prompt, detailed evaluation, and PE response teams may help with rapid assessment and initiation of therapy. More clinical trial data are needed to guide clinicians in the management of acute intermediate- and high-risk PE patients.
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Affiliation(s)
- Victor F Tapson
- Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Thalians Building Room w155, 8730 Alden Drive, Los Angeles, CA 90048, USA.
| | - Aaron S Weinberg
- Cedars-Sinai Medical Center, Thalians Building, 8730 Alden Drive, Los Angeles, CA 90048, USA
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Farsad K, Kapoor BS, Fidelman N, Cain TR, Caplin DM, Eldrup-Jorgensen J, Gupta A, Higgins M, Hohenwalter EJ, Lee MH, McBride JJ, Minocha J, Rochon PJ, Sutphin PD, Lorenz JM. ACR Appropriateness Criteria® Radiologic Management of Iliofemoral Venous Thrombosis. J Am Coll Radiol 2020; 17:S255-S264. [PMID: 32370969 DOI: 10.1016/j.jacr.2020.01.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 11/16/2022]
Abstract
Iliofemoral venous thrombosis carries a high risk for pulmonary embolism, recurrent deep vein thrombosis, and post-thrombotic syndrome complicating 30% to 71% of those affected. The clinical scenarios in which iliofemoral venous thrombosis is managed may be diverse, presenting a challenge to identify optimum therapy tailored to each situation. Goals for management include preventing morbidity from venous occlusive disease, and morbidity and mortality from pulmonary embolism. Anticoagulation remains the standard of care for iliofemoral venous thrombosis, although a role for more aggressive therapies with catheter-based interventions or surgery exists in select circumstances. Results from recent prospective trials have improved patient selection guidelines for more aggressive therapies, and have also demonstrated a lack of efficacy for certain conservative therapies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Khashayar Farsad
- Charles T. Dotter Department of Interventional Radiology, Portland, Oregon.
| | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Thomas R Cain
- Desert Regional Medical Center, Palm Springs, California
| | - Drew M Caplin
- Zucker School of Medicine at Hofstra Northwell, Hempstead, New York
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | | | | | - Margaret H Lee
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Jeet Minocha
- University of California San Diego, San Diego, California
| | - Paul J Rochon
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
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10
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Abstract
Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, EA3920, University Hospital Besançon, Boulevard Fleming, 25030 Besançon, France
| | - Fiona Ecarnot
- Department of Cardiology, EA3920, University Hospital Besançon, Boulevard Fleming, 25030 Besançon, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Besançon, Boulevard Fleming, 25030 Besançon, France
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Abstract
Acute pulmonary embolism (PE) is a major public health problem and accounts for 100,000-180,000 deaths per year in the United States. Current prognostic stratification separates acute PE into massive, submassive, and low-risk by the presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive and low-risk PE have mortality rates of 25-65%, 3%, and < 1%, respectively. In this review we will focus on therapies currently available to manage acute massive and submassive PE.
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12
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Jaber WA, McDaniel MC. Catheter-Based Embolectomy for Acute Pulmonary Embolism: Devices, Technical Considerations, Risks, and Benefits. Interv Cardiol Clin 2017; 7:91-101. [PMID: 29157528 DOI: 10.1016/j.iccl.2017.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A significant number of patients with high-risk pulmonary embolism have contraindications to thrombolytic therapy. Catheter-based therapy may be helpful and consists of a multitude of catheters and techniques, some old and some new. Although there are few data supporting the use of any of these techniques, there has been a recent rise in interest and use of catheter-based pulmonary embolectomy. This text describes the contemporary devices used in pulmonary embolism treatment, discusses their challenges, and proposes some future directions.
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Affiliation(s)
- Wissam A Jaber
- Division of Cardiology, Emory University School of Medicine, 550 Peachtree Street, MOT 6th Floor, Atlanta, GA 30308, USA.
| | - Michael C McDaniel
- Division of Cardiology, Emory University School of Medicine, 550 Peachtree Street, MOT 6th Floor, Atlanta, GA 30308, USA
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Abstract
Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with cardiogenic shock and may be of benefit in select normotensive patients with right heart strain. Percutaneous catheter-based techniques (catheter-directed mechanical thrombectomy, clot maceration, and/or pharmacologic thrombolysis) as an alternative or adjunct to systemic thrombolysis can rapidly debulk central clot in patients with shock. Catheter-directed thrombolysis, which uses a low-dose intraclot prolonged thrombolytic infusion, is a promising but insufficiently studied therapy for patients presenting with acute intermediate-risk PE.
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Affiliation(s)
- Bedros Taslakian
- Vascular and Interventional Radiology, Department of Radiology, NYU Langone Medical Center, 550 First Avenue, 2nd Floor (VIR Section), New York, NY 10016, USA
| | - Akhilesh K Sista
- Vascular and Interventional Radiology, Department of Radiology, NYU Langone Medical Center, 660 First Avenue, 3rd Floor, New York, NY 10016, USA.
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14
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Li XF, Wan CQ, He XG, Qiu JY, Li DY, Sun YX, Mao YM. Catheter-directed therapy as a treatment for submassive pulmonary embolism: A meta-analysis. Life Sci 2017; 188:17-25. [PMID: 28864224 DOI: 10.1016/j.lfs.2017.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/21/2017] [Accepted: 08/29/2017] [Indexed: 12/28/2022]
Abstract
AIMS Catheter-directed therapy (CDT) is included in the guidelines for diagnosing and treating massive pulmonary embolism. However, few studies have evaluated the efficacy of CDT as a treatment for submassive pulmonary embolism (SPE). Therefore, we used evidence-based medicine to evaluate the effectiveness and safety of CDT in treating SPE. METHODS Search terms describing CDT in SPE and patients with intermediate pulmonary embolism were entered into the PubMed, Embase and Cochrane Library databases to identify relevant articles without language restrictions published between January 1990 and December 2016. A quality assessment and data extraction were performed by two investigators. The clinical efficacy of and major complications associated with treatment were analysed using a fixed effects model. KEY FINDINGS A total of 552 patients in 16 studies were included in this meta-analysis. The clinical success rate in CDT was approximately 100% (95% confidence interval (CI): 99%, 100%), the primary bleeding rate was 0.02% (95% CI: 0%, 0.05%), and mortality during hospitalization was approximately 0% (95% CI: 0%, 0.01%). The mean decrease in pulmonary artery systolic pressure after treatment was -14.9% (95% CI: -19.25%, -10.55%), and the mean post-treatment change in the ratio of the right to the left ventricle (RV/LV) was -0.35% (95% CI: -0.48%, -0.22%). SIGNIFICANCE CDT is effective and safe as a treatment for SPE and could be a first-line treatment for SPE under specific conditions.
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Affiliation(s)
- Xiao-Fang Li
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China.
| | - Cheng-Quan Wan
- Department of Neonatology, The Women and Children Health Care Center of Luoyang, Henan Province, China
| | - Xue-Gai He
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Jia-Yong Qiu
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Dan-Yang Li
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Yu-Xia Sun
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Yi-Min Mao
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
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15
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Gao S, Zhu Q, Dong X, Chen Z, Liu Z, Xie F. Guided longer pulses from a diagnostic ultrasound and intraclot microbubble enhanced catheter-directed thrombolysis in vivo. J Thromb Thrombolysis 2017; 44:48-56. [PMID: 28417266 DOI: 10.1007/s11239-017-1500-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The mechanism of ultrasound thrombolysis (UT) is generally attributed to cavitation. The insufficiency of microbubbles (MB) to serve as cavitation nuclei in the vessel-obstructing thrombi significantly reduces the effectiveness of UT. Taking advantage of the widely performed catheter-directed therapy (CDT), in a thrombo-embolized rabbit IVC model with a simultaneous catheter directed rt-PA thrombolysis procedure, guided moderate mechanical index longer pulses from a modified diagnostic ultrasound transducer, combined with an intraclot infusion of MB, significantly accelerated the thrombolysis process. The higher thrombolysis efficacy score and consistent elevated post-treatment plasma concentration level of D-Dimer, a product of fibrinolysis, both indicated the superiority of CDT + UT over CDT/UT alone. Pathologic examination of the treated occluded IVC segments revealed an almost complete dissolution of the thrombi treated with CDT + UT. There was no evidences of thrombo-embolism or local thrombus formation in the cardiac-pulmonary vessels. Combined with intraclot infusion of MB, guided longer pulse ultrasound from a diagnostic transducer is able to safely and significantly improve a catheter-directed thrombolysis procedure. It thus has the potential to achieve earlier clot removal, administration of a lower dosage of thrombolytic agent and, consequently, a lower incidence of thrombolysis-related side effects.
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Affiliation(s)
- Shunji Gao
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Qiong Zhu
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Xiaoxiao Dong
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Zhong Chen
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Zheng Liu
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Feng Xie
- Internal Medicine Cardiology, University of Nebraska Medical Center, Omaha, NE, USA
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Zuin M, Rigatelli G, Ferraresi S, Zonzin P, Roncon L. Acute pulmonary embolism after post-traumatic spinal epidural hematoma: Use of catheter-direct treatment. Cardiovasc Revasc Med 2016; 18:274-275. [PMID: 27743817 DOI: 10.1016/j.carrev.2016.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 09/16/2016] [Accepted: 09/23/2016] [Indexed: 01/27/2023]
Abstract
We report the case of a 35-year-old man who developed a massive pulmonary embolism (PE) after spine surgery. After an accidental axial fall, the patient developed a spinal epidural hematoma (SHE). Because major trauma, recent surgery and known bleeding risk are considered absolute contraindications to systemic thrombolysis, the patient was treated with catheter-directed therapy (CDT). CDT remains a useful treatment in massive PE, especially when systemic thrombolysis is contraindicated or has failed.
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Affiliation(s)
- Marco Zuin
- Department of Cardiology, Santa Maria della Misericordia, Rovigo, Italy; Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, 44124, Cona, Ferrara, Italy
| | - Gianluca Rigatelli
- Department of Cardiovascular Diagnosis and Endoluminal Interventions, Santa Maria della Misericordia Hospital, 45100, Rovigo, Italy
| | - Stefano Ferraresi
- Department of Neurosurgery, Santa Maria della Misericordia, Rovigo, Italy
| | - Pietro Zonzin
- Department of Cardiology, Santa Maria della Misericordia, Rovigo, Italy
| | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia, Rovigo, Italy.
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17
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Buccheri D, Inga G, Piraino D, Andolina G. Pulmonary embolism treatment: Why not a catheter-directed strategy? Int J Cardiol 2016; 221:350-1. [PMID: 27404704 DOI: 10.1016/j.ijcard.2016.06.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/28/2016] [Indexed: 11/21/2022]
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