Ultrasound-accelerated thrombolysis in high-risk perioperative pulmonary embolism: two case reports and review of literature

Abstract Introduction Treatment of high-risk pulmonary embolism (PE) in perioperative patients remains challenging. Systemic thrombolysis is associated with a high risk of major bleedings and intracranial haemorrhage. High mortality rates are reported for open pulmonary embolectomy. Therefore, postoperative surgical patients may benefit substantially from catheter-directed ultrasound-accelerated thrombolysis (USAT). Case presentation We report two cases of high-risk perioperative PE. Both patients developed severe haemodynamic instability leading to cardiac arrest. After the implantation of a veno-arterial extracorporeal membrane oxygenation (ECMO), they were both successfully treated with USAT. Adequate improvement of right ventricular function was achieved; thus, ECMO could be successfully weaned after 3 and 4 days, respectively. Both patients showed favourable outcomes and could be discharged to rehabilitation. Conclusion Current guidelines on treatment of PE offer no specific therapies for perioperative patients with high-risk PE. However, systemic thrombolysis is often excluded due to the perioperative setting and the risk of major bleeding. Catheter-directed thrombolysis was shown to utilise less thrombolytic agent while obtaining comparable thrombolytic effects. The risk for major bleeding (including intracranial haemorrhage) is also significantly lowered. Until further trials determining the value of adopted treatment strategies of high-risk PE in perioperative patients are available, USAT should be considered in similar cases.

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Ultrasound-Accelerated Thrombolysis in High-Risk Perioperative Pulmonary Embolism: Two Case Reports and Review of Literature

10.21203/rs.3.rs-82629/v1 ◽

2020 ◽

Author(s):

Götz Schmidt ◽

Fabian Edinger ◽

Christian Koch ◽

Matthias Wolff ◽

Christoph Biehl ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Major Bleeding ◽

Intracranial Haemorrhage ◽

Case Reports ◽

Haemodynamic Instability ◽

Pulmonary Embolectomy ◽

Systemic Thrombolysis ◽

Catheter Directed Thrombolysis ◽

Randomised Controlled

Abstract Background: Treatment of high-risk pulmonary embolism (PE) in perioperative patients remains challenging. Systemic thrombolysis is associated with a high risk of major bleedings and intracranial haemorrhage. High mortality rates are reported for open pulmonary embolectomy. Therefore, postoperative surgical patients may benefit substantially from catheter-directed ultrasound-accelerated thrombolysis (USAT).Case summary: We report two cases of high-risk perioperative PE. Both patients developed severe haemodynamic instability leading to cardiac arrest. After the implantation of a veno-arterial extracorporeal membrane oxygenation (ECMO), they were both successfully treated with USAT. Adequate improvement of right ventricular function was achieved; thus, ECMO could be successfully weaned after three and four days, respectively. Both patients showed favourable outcomes and could be discharged to rehabilitation. Discussion: The current European guideline on treatment of PE offers no specific therapies for perioperative patients with high-risk PE. However, systemic thrombolysis is often excluded due to the perioperative setting and the risk of major bleeding. Catheter-directed thrombolysis was shown to utilise less thrombolytic agent while obtaining comparable thrombolytic effects. The risk for major bleeding (including intracranial haemorrhage) is also significantly lowered. Conclusion: Further prospective randomised controlled trials are necessary to determine the value of USAT treatment of high-risk PE in perioperative patients.

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P106: Systemic thrombolysis for suspected high-risk pulmonary embolism: a retrospective medical record review

CJEM ◽

10.1017/cem.2018.304 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S94-S94

Author(s):

A. Mulla ◽

K. de Wit

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Major Bleeding ◽

Treatment Guidelines ◽

Demographic Variable ◽

Univariate Analysis ◽

Fibrinolytic Therapy ◽

Moderate Risk ◽

Systemic Thrombolysis ◽

History Of

Introduction: Current treatment guidelines advocate for the aggressive management of both high-risk and subsets of moderate-risk pulmonary embolism (PE) with fibrinolytic therapy. However, there is limited evidence on the risks and benefits of fibrinolytic therapy in PE, with mortality improvement still to be proven. This study aimed to report the incidence of major bleeding and death after thrombolysis for PE. Methods: A health records review was performed on data from two hospitals between 2007 and 2017. Pharmacy identified all patients who had received either alteplase or tenecteplase. Trained abstractors reviewed each chart to determine the indication for thrombolytic therapy. Patients were included if they received systemic thrombolysis for diagnosed or presumed PE. Data was extracted on 30-day mortality, International Society of Thrombosis and Hemostasis defined major bleeding within 30 days, premorbid anticoagulant and antiplatelet prescription, age, sex, comorbidities, renal function, history of bleeding, type and dose of thrombolytic and category of PE (high or moderate risk). Results: 1534 patients were identified, of which 72 received systemic thrombolysis for PE. The median age was 57, 34 were male, 17 with a history of venous thrombosis and 12 with cancer. Fifty-four were classified as having high-risk PE, of whom 39 received cardiopulmonary resuscitation (CPR) when thrombolysis was administered. Formal confirmatory imagining for PE was obtained in only 23/39 patients who were in cardiac arrest. Eighteen patients were classified as moderate-risk PE. The incidence of major bleeding was 28/54 (52%, 95% CI 39-65%), and 3/18 (17%, 95% CI 6-39%) for the high and moderate risk groups respectively. There were 4 intracranial bleeds, all in the high-risk PE group. The only significant predictor of major bleeding was the need for CPR at the point of administration of the thrombolytic agent (OR 2.6, 95% CI 1.0-7.5, adjusted for age). Thirty-four patients died within 30 days (47%, 95% CI 36-59%), all in the high-risk PE group. Death was not associated with any demographic variable on univariate analysis. Death occurred in 28/39 (72%, 95%CI 56-83%) patients who received CPR and 6/33 (18%, 95% CI 9-34%) who did not. Conclusion: We found a high incidence of 30-day major bleeding and death following administration of thrombolysis for PE which will help inform future prognostic discussions in our institution.

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

Vascular Medicine ◽

10.1177/1358863x20967415 ◽

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.

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Treatment Difficulties in High Risk Pulmonary Embolism. A Case Report

Journal Of Cardiovascular Emergencies ◽

10.1515/jce-2016-0007 ◽

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.

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Outcomes of catheter-directed versus systemic thrombolysis for the treatment of pulmonary embolism: A real-world analysis of national administrative claims

Vascular Medicine ◽

10.1177/1358863x20903371 ◽

2020 ◽

Vol 25 (4) ◽

pp. 334-340

Author(s):

Bram J Geller ◽

Srinath Adusumalli ◽

Steven C Pugliese ◽

Sameed Ahmed M Khatana ◽

Ashwin Nathan ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Real World ◽

Large Scale ◽

Randomized Clinical Trials ◽

Administrative Database ◽

Administrative Claims ◽

Systemic Thrombolysis ◽

Catheter Directed Thrombolysis ◽

Comparative Safety

Catheter-directed thrombolysis (CDT) and systemic thrombolysis (ST) are used to treat intermediate/high-risk pulmonary embolism (PE) in the absence of comparative safety and effectiveness data. We utilized a large administrative database to perform a comparative safety and effectiveness analysis of catheter-directed versus systemic thrombolysis. From the Optum® Clinformatics® Data Mart private-payer insurance claims database, we identified 100,744 patients hospitalized with PE between 2004 and 2014. We extracted demographic characteristics, high-risk PE features, components of the Elixhauser Comorbidity Index, and outcomes including intracranial hemorrhage (ICH), all-cause bleeding, and mortality among all patients receiving CDT and ST. We used propensity score methods to compare outcomes between matched cohorts adjusted for observed confounders. A total of 1915 patients (1.9%) received either CDT ( n = 632) or ST ( n = 1283). Patients in the CDT group had fewer high-risk features including less shock (5.4 vs 11.1%; p < 0.001) and cardiac arrest (6.8 vs 11.0%; p = 0.004). In 1:1 propensity-matched groups, ICH rates were 1.9% in both the CDT and ST groups ( p = 1.0). All-cause bleeding was higher in the CDT group (15.9 vs 8.7%; p < 0.001), while in-hospital mortality was lower (6.5 vs 10.0%; p = 0.02). Among a nationally representative cohort of patients with PE at higher risk for mortality, CDT was associated with similar ICH rates, increased all-cause bleeding, and lower short and intermediate-term mortality when compared with ST. The competing risks and benefits of CDT in real-world practice suggest the need for large-scale randomized clinical trials with appropriate comparator arms.

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COVID-19 complicated by pulmonary embolism treated with catheter directed thrombectomy

VASA ◽

10.1024/0301-1526/a000880 ◽

2020 ◽

Vol 49 (4) ◽

pp. 333-337 ◽

Cited By ~ 3

Author(s):

Francisco Leonardo Galastri ◽

Leonardo Guedes Moreira Valle ◽

Breno Boueri Affonso ◽

Marcela Juliano Silva ◽

Rodrigo Gobbo Garcia ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Dynamic Process ◽

Therapeutic Option ◽

Massive Pulmonary Embolism ◽

Percutaneous Intervention ◽

Thromboembolic Events ◽

Emergency Center ◽

Catheter Directed Thrombolysis

Summary: COVID-19 is a recently identified illness that is associated with thromboembolic events. We report a case of pulmonary embolism in a patient with COVID-19, treated by catheter directed thrombectomy. A 57 year old patient presented to the emergency center with severe COVID-19 symptoms and developed massive pulmonary embolism. The patient was treated with catheter directed thrombolysis (CDT) and recovered completely. Coagulopathy associated with COVID-19 is present in all severe cases and is a dynamic process. We describe a case of massive/high risk pulmonary embolism, in a patient with COVID-19 receiving full anticoagulation, who was treated by percutaneous intervention. CDT can be an additional therapeutic option in patients with COVID-19 and pulmonary embolism that present with rapid clinical collapse.

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Acute pulmonary embolism in COVID-19 patient: a case report of free-floating right heart thrombus successfully treated with fibrinolysis

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa388 ◽

2020 ◽

Author(s):

Fernando Scudiero ◽

Antonino Pitì ◽

Roberto Keim ◽

Guido Parodi

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Retrospective Studies ◽

Right Heart ◽

Clinical Issue ◽

Systemic Thrombolysis ◽

Case Summary ◽

High Prevalence ◽

Life Threatening ◽

Complex Scenario

Abstract Background Despite the fast-growing understanding of the coronavirus disease 2019 (COVID-19), patient management remains largely empirical or based on retrospective studies. In this complex scenario, an important clinical issue appears to be represented by the high prevalence of thromboembolic events, but the data regarding high-risk pulmonary embolism (PE) is still not available. Case summary A patient with COVID-19 developed sudden shortness of breath and hypoxia. Early echocardiographic diagnosis of high-risk PE related to right heart thrombus was performed. Systemic thrombolysis was administered with excellent clinical and haemodynamic response. Discussion Pulmonary thromboembolism is a common occurrence in severe COVID-19 infection. In our experience, systemic thrombolysis proved to be effective and for this reason may be considered for life-threatening PE in COVID-19 patients.

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