Systemic thrombolysis increases hemorrhagic stroke risk without survival benefit compared with catheter-directed intervention for the treatment of acute pulmonary embolism

BackgroundSimilar trends of management and in-hospital mortality of acute pulmonary embolism (PE) have been reported in European and American populations. However, these tendencies were not clear in Asian countries.ObjectivesWe retrospectively analyzed the trends of risk stratification, management and in-hospital mortality for patients with acute PE through a multicenter registry in China (CURES).MethodsAdult patients with acute symptomatic PE were included between 2009 and 2015. Trends in disease diagnosis, treatment and death in hospital were fully analyzed. Risk stratification was retrospectively classified by hemodynamical status and the simplified Pulmonary Embolism Severity Index (sPESI) score according to the 2014 European Society of Cardiology/European Respiratory Society guidelines.ResultsAmong overall 7438 patients, the proportions with high (hemodynamically instability), intermediate (sPESI≥1) and low (sPESI=0) risk were 4.2%, 67.1% and 28.7%, respectively. Computed tomographic pulmonary angiography was the widely employed diagnostic approach (87.6%) and anticoagulation was the frequently adopted initial therapy (83.7%). Between 2009 and 2015, a significant decline was observed for all-cause mortality (from 3.1% to 1.3%, adjusted Pfor trend=0.0003), with a concomitant reduction in use of initial systemic thrombolysis (from 14.8% to 5.0%, Pfor trend<0.0001). The common predictors for all-cause mortality shared by hemodynamically stable and unstable patients were co-existing cancer, older age, and impaired renal function.ConclusionsThe considerable reduction of mortality over years was accompanied by changes of initial treatment. These findings highlight the importance of risk stratification-guided management throughout the nation.

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CURRENT VIEW ON ANTICOAGULANT AND THROMBOLYTIC TREATMENT OF ACUTE PULMONARY EMBOLISM

The Russian Archives of Internal Medicine ◽

10.20514/2226-6704-2019-9-5-348-366 ◽

2019 ◽

Vol 9 (5) ◽

pp. 348-366

Author(s):

G. G. Taradin ◽

G. A. Ignatenko ◽

N. T. Vatutin ◽

I. V. Kanisheva

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Acute Pulmonary Embolism ◽

Oral Anticoagulants ◽

Medical Intervention ◽

Bleeding Complications ◽

Current View ◽

Anticoagulant Treatment ◽

Thrombolytic Treatment ◽

Systemic Thrombolysis

The presented review concerns contemporary views on specific aspects of anticoagulant and thrombolytic treatment of venous thromboembolism and mostly of acute pulmonary embolism. Modern classifications of patients with acute pulmonary embolism, based on early mortality risk and severity of thromboembolic event, are reproduced. The importance of multidisciplinary approach to the management of patients with pulmonary embolism with the assistance of cardiologist, intensive care specialist, pulmonologist, thoracic and cardiovascular surgeon, aimed at the management of pulmonary embolism at all stages: from clinical suspicion to the selection and performing of any medical intervention, is emphasized. Anticoagulant treatment with the demonstration of results of major trials, devoted to efficacy and safety evaluation of anticoagulants, is highlighted in details. Moreover, characteristics, basic dosage and dosage scheme of direct (new) oral anticoagulants, including apixaban, rivaroxaban, dabigatran, edoxaban and betrixaban are described in the article. In particular, the management of patients with bleeding complications of anticoagulant treatment and its application in cancer patients, who often have venous thromboembolism, is described. Additionally, modern approaches to systemic thrombolysis with intravenous streptokinase, urokinase and tissue plasminogen activators are presented in this review. The indications, contraindications, results of clinical trials devoted to various regimens of thrombolytic therapy, including treatment of pulmonary embolism by lower doses of fibrinolytic agents, are described.

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Catheter-Directed Interventions Compared With Systemic Thrombolysis Achieve Equivalent Ventricular Function Recovery at a Potentially Lower Complication Rate for Acute Pulmonary Embolism

Journal of Vascular Surgery Venous and Lymphatic Disorders ◽

10.1016/j.jvsv.2016.10.029 ◽

2017 ◽

Vol 5 (1) ◽

pp. 153

Author(s):

Efthymios D. Avgerinos ◽

Adham Abou Ali ◽

Nathan Liang ◽

Belinda Rivera-Lebron ◽

Catalin Toma ◽

...

Keyword(s):

Pulmonary Embolism ◽

Ventricular Function ◽

Complication Rate ◽

Acute Pulmonary Embolism ◽

Systemic Thrombolysis ◽

Function Recovery ◽

Lower Complication ◽

Lower Complication Rate

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Reperfusion Treatment for Acute Pulmonary Embolism

Hämostaseologie ◽

10.1055/s-0038-1641717 ◽

2018 ◽

Vol 38 (02) ◽

pp. 98-105 ◽

Cited By ~ 1

Author(s):

Rolf Engelberger ◽

Nils Kucher

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Treatment Options ◽

Bleeding Risk ◽

Good Alternative ◽

Reperfusion Therapy ◽

Systemic Thrombolysis ◽

Favourable Safety ◽

Favourable Safety Profile ◽

Surgical Embolectomy

AbstractDue to the manifold treatment options for the management of acute pulmonary embolism, state-of-the-art management requires risk stratification for choosing the adapted treatment for each patient. Reperfusion therapy is an integral part of therapy for patients with pulmonary embolism at high risk for mortality, but its role in patients with intermediate risk pulmonary embolism is more debated. The largest amount of evidence exists for systemic thrombolysis, which is an efficient therapy, but at the prize of an increased bleeding risk. In recent years, various types of catheter-based reperfusion therapies have been introduced, and evidence is growing that this therapy is as efficient as systemic thrombolysis, but with a more favourable safety profile. Surgical embolectomy remains a good alternative for unstable patients, especially for those with absolute contraindications for thrombolysis or after failed systemic thrombolysis. While the early benefits of reperfusion therapy are well documented, evidence for long-term benefit is still scarce. The scope of this review is to summarize the evidence for the currently available reperfusion therapies in the management of acute pulmonary embolism.

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Interventional Reperfusion Strategies for Acute Pulmonary Embolism

Praxis ◽

10.1024/1661-8157/a003737 ◽

2021 ◽

Vol 110 (13) ◽

pp. 743-751

Author(s):

Dominik F. Draxler ◽

Stefan Stortecky

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Stroke Risk ◽

Interventional Treatment ◽

Therapeutic Approaches ◽

Early Reperfusion ◽

The Third ◽

Catheter Directed Thrombolysis ◽

Life Threatening ◽

Reperfusion Strategy

Abstract. Acute pulmonary embolism (APE) is a common, potentially life-threatening cardiovascular emergency, and represents the third leading cause of cardiovascular mortality after myocardial infarction and stroke. Risk stratification is important to guide the management of APE, as an early reperfusion strategy is associated with improved clinical outcomes in specific high-risk conditions. Pulmonary artery reperfusion is commonly achieved by systemic intravenous administration of thrombolytic drugs, but catheter-directed thrombolysis (CDThr) and interventional techniques of catheter-based embolectomy provide novel therapeutic approaches with an improved risk-benefit ratio. Future trials will help to determine when to use these different devices in massive or sub-massive APE, and which patient population is likely to benefit from interventional treatment.

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Intrapulmonary Artery Thrombolysis in Acute Pulmonary Embolism: Case Series from King Chulalongkorn Memorial Hospital Experience

Journal of the Medical Association of Thailand ◽

10.35755/jmedassocthai.2021.08.11444 ◽

2021 ◽

Vol 104 (8) ◽

pp. 1376-1380

Keyword(s):

Pulmonary Embolism ◽

Plasminogen Activator ◽

Acute Pulmonary Embolism ◽

Case Series ◽

Systemic Thrombolysis ◽

Tissue Plasminogen ◽

Surgical Embolectomy ◽

Surgical Thrombectomy ◽

Acute Pe

Acute pulmonary embolism (PE) is a life-threatening condition. In patient who has contraindication for systemic thrombolysis and inappropriate for surgical embolectomy, there is a role of catheter interventions. However, the data are limited. The aim of the present report was to assess a role of intrapulmonary artery thrombolysis bolus in acute PE. A retrospective review of the use of intrapulmonary artery thrombolysis in acute PE. The data were collected from 14 patients with massive or submassive PE who had contraindication or inappropriate for systemic thrombolysis and unsuitable for surgical embolectomy. After intrapulmonary thrombolysis was given, patients were followed clinically and hemodynamically until discharged and after 1 month. Pulmonary pressure was collected at pre and post intervention. Of the 14 patients (age 59±19 years, 78.6% female), 86% were diagnosed as submassive PE. Mean dose of tissue plasminogen activator (rt-PA) was 28±14 mg given as bolus and continuous infusion (19±10 hours). One patient died after completion of intrapulmonary infusion rt-PA at day 90, which did not relate to PE and the treatment. After intervention, mean PA pressure was significantly reduced from 32.3±6.0 to 21.0±4.3 mmHg (p<0.001). Three patients (21%) had minor bleeding (hematoma at access site). The present case series showed that intrapulmonary infusion of rt-PA was effective and safe in patient with massive and submassive PE who had contraindication or inappropriate to systemic thrombolysis or inoperable surgical thrombectomy. Keywords: Acute pulmonary embolism; Intrapulmonary thrombolysis; Tissue plasminogen activator; Surgical thrombectomy

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Systemic Thrombolysis Compared to Catheter Directed Thrombolysis in Acute Pulmonary Embolism

CHEST Journal ◽

10.1378/chest.2265015 ◽

2015 ◽

Vol 148 (4) ◽

pp. 919A

Author(s):

Nileshkumar Patel ◽

Amina Saqib ◽

Jasvinder Singh ◽

Abdul Siddiqui ◽

Uroosa Ibrahim ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Systemic Thrombolysis ◽

Catheter Directed Thrombolysis

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Use and clinical outcome of veno-arterial extracorporeal membrane oxygenation in patients with acute pulmonary embolism and cardiopulmonary resuscitation

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.146 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

L Hobohm ◽

I Sagoschen ◽

T Gori ◽

FP Schmidt ◽

T Muenzel ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Mortality Rate ◽

Cardiopulmonary Resuscitation ◽

Acute Pulmonary Embolism ◽

Treatment Strategies ◽

Hospital Death ◽

Systemic Thrombolysis ◽

Va Ecmo ◽

Acute Pe

Abstract Funding Acknowledgements Type of funding sources: None. Background Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with acute pulmonary embolism (PE) and concomitant cardiac arrest with the necessity of cardiopulmonary resuscitation (CPR). Little is known about the use and clinical outcome of veno-arterial (VA)-ECMO and adjunctive treatment strategies in patients with acute PE and CPR. Purpose In this context, we aimed to investigate the use of VA-ECMO alone or after systemic thrombolysis and its impact on in-hospital outcomes of patients with acute PE and CPR. Methods We analyzed data on the characteristics, treatments and in-hospital outcomes for all patients with acute PE (ICD-code I26) and CPR in Germany between the years 2005 and 2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2018, own calculations). Results Between 2005 and 2018, 1,172,354 patients with acute PE (53.5% females) were included in this analysis; of those, 77,196 (6.5%) presented with cardiac arrest and CPR. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority received a combination of thrombolysis + VA-ECMO (n = 165; 0.2%) or singular approach with VA-ECMO treatment alone (n = 588; 0.8%). The overall in-hospital mortality rate of PE patients with cardiac arrest was high with 83.8%. Non-survivors were considerable older than survivors (74 [IQR 63-81] vs. 69 [58-77]). In patients treated with VA ECMO alone the mortality rate was 71.1% and 69.7% when patients received Thrombolysis + VA-ECMO. Patients, who received thrombolysis without VA-ECMO had a higher mortality rate (83.8%). In order to investigate the impact of those different treatment strategies, a multivariate logistic regression analysis (adjusted for age, sex and comorbidities) demonstrated the lowest risk for in-hospital death in patients, who underwent the combination of Thrombolysis + VA-ECMO (OR, 0.61 [95% CI, 0.43-0.86], P = 0.004) or VA-ECMO alone (OR, 0.70 [0.58-0.84], P < 0.001) compared to patients without VA-ECMO and without thrombolysis. Use of thrombolysis alone in patients with PE and CPR lowering the risk regarding in-hospital death as well (OR, 0.95 [0.91-0.99], P = 0.013). Regarding temporal trends, the annual use of VA-ECMO increased from 0 in the year 2005 to the number of 138 in 2018 (ß 6.13 (4.62-6.76); p < 0.001) as well as for the combined treatment Thrombolysis + VA-ECMO (from 0 to 39 [ß 4.28 (3.68-4.89); p < 0.001]). Conclusion Patients with acute PE and CPR had a very high in-hospital mortality rate. Our data suggest, that VA-ECMO alone or after systemic thrombolysis should be considered as an option in this outstanding life-threatening situation to improve in-hospital outcome. Furthermore, our data highlight a marked increase in the number of PE patients treated with VA-ECMO indicating the structural health care progress between 2005 and 2018.

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Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence

European Heart Journal Supplements ◽

10.1093/eurheartj/suz224 ◽

2019 ◽

Vol 21 (Supplement_I) ◽

pp. I23-I30 ◽

Cited By ~ 4

Author(s):

Romain Chopard ◽

Fiona Ecarnot ◽

Nicolas Meneveau

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Pressure Overload ◽

Efficacy And Safety ◽

Bleeding Events ◽

Systemic Thrombolysis ◽

Risk Of Death ◽

Risk Of Bleeding ◽

Catheter Directed Thrombolysis ◽

Acute Pe

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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