Aggressive Therapy for Acute Pulmonary Embolism: Systemic Thrombolysis and Catheter-Directed Approaches

2021 ◽  
Author(s):  
Thomas M. Todoran ◽  
Bradley Petkovich
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Evidence ◽  
The United States ◽  
Population Based ◽  
Systemic Thrombolysis ◽  
Stroke Population ◽  
Catheter Directed Thrombolysis ◽  
Surgical Embolectomy ◽  
Contemporary Management ◽  
Acute Pe

AbstractVenous thromboembolism (VTE) is the third most common cause of cardiovascular disease after myocardial infarction and stroke. Population-based studies estimate that up to 94,000 new cases of pulmonary embolism (PE) occur in the United States annually with an increasing incidence with age. Mortality from PE is the greatest in the first 24 hours, with a decreased survival extending out 3 months. Thus, acute PE is a potentially fatal illness if not recognized and treated in a timely manner. Contemporary management includes systemic anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. This article reviews current clinical evidence and societal guidelines for the use of systemic and catheter-directed thrombolysis for treatment of acute PE.

Bleeding, death, and costs of care during hospitalization for acute pulmonary embolism: Insights from the Saint Luke’s Outcomes of Pulmonary Embolism (SLOPE) study

2020 ◽  
pp. 1358863X2096741
Author(s):  
Matthew C Bunte ◽  
Kensey Gosch ◽  
Ahmed Elkaryoni ◽  
Anas Noman ◽  
Erin Johnson ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Major Bleeding ◽  
Hospital Readmission ◽  
Common Adverse Event ◽  
Hospital Length Of Stay ◽  
Hospital Death ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Acute Pe

Limited data exist that comprehensively describe the practical management, in-hospital outcomes, healthcare resource utilization, and rates of post-hospital readmission among patients with submassive and massive pulmonary embolism (PE). Consecutive discharges for acute PE were identified from a single health system over 3 years. Records were audited to confirm presence of acute PE, patient characteristics, disease severity, medical treatment, and PE-related invasive therapies. Rates of in-hospital major bleeding and death, hospital length of stay (LOS), direct costs, and hospital readmission are reported. From January 2016 to December 2018, 371 patients were hospitalized for acute massive or submassive PE. In-hospital major bleeding (12.1%) was common, despite low utilization of systemic thrombolysis (1.8%) or catheter-directed thrombolysis (3.0%). In-hospital death was 10-fold higher among massive PE compared to submassive PE (36.6% vs 3.3%, p < 0.001). Massive PE was more common during hospitalizations not primarily related to venous thromboembolism, including hospitalizations primarily for sepsis or infection (26.8% vs 8.2%, p = 0.001). Overall, the median LOS was 6.0 days (IQR, 3.0–11.0) and the median standardized direct cost of admissions was $10,032 (IQR, $4467–$20,330). Rates of all-cause readmission were relatively high throughout late follow-up but did not differ between PE subgroups. Despite low utilization of thrombolysis, in-hospital bleeding remains a common adverse event during hospitalizations for acute PE. Although massive PE is associated with high risk for in-hospital bleeding and death, those successfully discharged after a massive PE demonstrate similar rates of readmission compared to submassive PE into late follow-up.

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

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

scholarly journals Treatment Difficulties in High Risk Pulmonary Embolism. A Case Report

2016 ◽  
Vol 2 (1) ◽  
pp. 37-42
Author(s):  
Balázs Bajka ◽  
Edvin Benedek ◽  
Alexandra Stănescu ◽  
Emese Rapolti ◽  
Monica Chițu ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Thrombolytic Agent ◽  
Bleeding Risk ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Increased Risk ◽  
Life Threatening ◽  
Surgical Embolectomy ◽  
High Bleeding Risk

Abstract Pulmonary embolism (PE) remains a common and potentially life-threatening cardiovascular emergency. Systemic thrombolysis with intravenous infusion of a thrombolytic agent is generally recommended for treatment of high risk PE. However, this method has known limitations in the presence of high bleeding risk. Catheter-directed thrombolysis has the potential to achieve the same benefits as systemic thrombolysis, with a lower risk of haemorrhage. The case presented is of a 67-year-old male patient with a high risk of pulmonary embolism and contraindications for systemic thrombolysis, in whom the presence of severe comorbidities presented an increased risk of surgical embolectomy, who was successfully treated by catheter-directed thrombolysis.

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

2019 ◽  
Vol 21 (Supplement_I) ◽  
pp. I23-I30 ◽  
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.

scholarly journals Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

2018 ◽  
Vol 35 (02) ◽  
pp. 122-128 ◽  
Author(s):  
Matthew Chiarello ◽  
Akhilesh Sista
Keyword(s):  
Pulmonary Embolism ◽  
The United States ◽  
Similar Efficacy ◽  
Major Hemorrhage ◽  
Systemic Thrombolysis ◽  
Clinical Endpoints ◽  
Catheter Directed Thrombolysis ◽  
Right Ventricular Strain ◽  
Submassive Pulmonary Embolism

AbstractAcute pulmonary embolism (PE) is a leading cause of morbidity and mortality in the United States. PE associated with right ventricular strain, termed submassive or intermediate-risk PE, is associated with an increased rate of clinical deterioration and short-term mortality. Trials have demonstrated systemic thrombolytics may improve patient outcomes, but they carry a risk of major hemorrhage. Catheter-directed thrombolysis (CDT) may offer similar efficacy to and a lower risk of catastrophic hemorrhage than systemic thrombolysis. Three prospective trials have evaluated CDT for submassive PE; ULTIMA, SEATTLE II, and PERFECT. These trials provide evidence that CDT may improve radiographic efficacy endpoints in submassive PE with acceptable rates of major hemorrhage. However, the lack of clinical endpoints, long-term follow-up, and adequate sample size limit their generalizability. Future trials should be adequately powered and controlled so that the short- and long-term effectiveness and safety of CDT can be definitively determined.

Pulmonary Embolism and Postoperative Care

2020 ◽  
pp. 59-72
Author(s):  
Daniel Haines ◽  
Joel Grigsby
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
Right Ventricular ◽  
Treatment Options ◽  
Right Ventricular Dysfunction ◽  
Myocardial Necrosis ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
The Stability ◽  
Acute Pe

This chapter assesses pulmonary embolism (PE), which is an obstruction of the pulmonary circulation by an occlusive material. The material may be thrombus, air, tumor, or fat. PE are classified as acute, subacute, or chronic; but they can be further classified into massive and submassive. Submassive PE is defined as an acute PE without systemic hypotension but with either right ventricular dysfunction or myocardial necrosis, while massive PE is defined as an acute PE with sustained shock. There are several strategies for treating PE depending on the stability of the patient and the location of the clot. Systemic thrombolysis, catheter-directed thrombolysis, and catheter-directed clot removal are all treatment options, if there are no contraindications. Bleeding risk is the largest contraindication for thrombolytic therapy. Meanwhile, surgical embolectomy is warranted for hemodynamically unstable patients as well as patients with contraindications to or who failed thrombolytic therapy and catheter-based approaches. Right ventricular failure is a serious complication following pulmonary embolectomy and is managed by a compilation of volume removal, inotropic support, pulmonary vasodilation, and mechanical support, if needed.

scholarly journals Pulmonary Embolism Response Teams: A Novel Approach for the Care of Complex Patients With Pulmonary Embolism

2018 ◽  
Vol 24 (9_suppl) ◽  
pp. 48S-55S ◽  
Author(s):  
Mateo Porres–Aguilar ◽  
Javier E. Anaya-Ayala ◽  
Gustavo A. Heresi ◽  
Belinda N. Rivera-Lebron
Keyword(s):  
Pulmonary Embolism ◽  
The United States ◽  
Cardiovascular Death ◽  
Pulmonary Embolectomy ◽  
Systemic Thrombolysis ◽  
Cardiopulmonary Support ◽  
Novel Approach ◽  
Adoption And Implementation ◽  
Complex Patients

Pulmonary embolism represents the third most common cause of cardiovascular death in the United States. Reperfusion therapeutic strategies such as systemic thrombolysis, catheter directed therapies, surgical pulmonary embolectomy, and cardiopulmonary support devices are currently available for patients with high- and intermediate-high–risk pulmonary embolism. However, deciding on optimal therapy may be challenging. Pulmonary embolism response teams have been designed to facilitate multidisciplinary decision-making with the goal to improve quality of care for complex cases with pulmonary embolism. Herein, we discuss the current role and strategies on how to leverage the strengths from pulmonary embolism response teams, its possible worldwide adoption, and implementation to improve survival and change the paradigm in the care of a potentially deadly disease.

scholarly journals TRENDS IN CATHETER DIRECTED THROMBOLYSIS AND SYSTEMIC THROMBOLYSIS FOR PULMONARY EMBOLISM TREATMENT: 2004-2014

2017 ◽  
Vol 69 (11) ◽  
pp. 1879
Author(s):  
Srinath Adusumalli ◽  
Bram Geller ◽  
Lin Yang ◽  
Jay Giri ◽  
Peter Groeneveld ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis

Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

2018 ◽  
Vol 52 (3) ◽  
pp. 195-201 ◽  
Author(s):  
Prasoon P. Mohan ◽  
John J. Manov ◽  
Francisco Contreras ◽  
Michael E. Langston ◽  
Mehul H. Doshi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Bleeding Risk ◽  
Right Heart ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Ultrasound Assisted ◽  
Vascular Obstruction ◽  
The Right ◽  
Pulmonary Vascular Obstruction

Purpose: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. Methods: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. Results: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. Conclusion: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

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