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 Effects of catheter-directed therapy for pulmonary embolism on pulmonary artery systolic pressure and PaO2/FiO2

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
M Muzzio ◽  
A Rossini ◽  
D Costa ◽  
L Garcia Iturralde ◽  
C Gonzalez ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Pulmonary Artery ◽  
Systolic Pressure ◽  
Bleeding Risk ◽  
Cardiovascular Death ◽  
Pulmonary Artery Systolic Pressure ◽  
Systemic Thrombolysis ◽  
Funding Sources ◽  
High Bleeding Risk

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary embolism (PE) is the third global cause of cardiovascular death. Treatment of high-risk cases and selected intermediate-risk cases is based on systemic thrombolysis, which can be inconvenient in patients with a contraindications for thrombolysis. Catheter-directed therapies are emerging as an alternative for treatment when there is an increased bleeding risk. Methods One-center retrospective study of patients with high or intermediate-high risk PE with contraindications for systemic thrombolysis. Catheter directed rheolytic thrombectomy or mechanical thrombectomy was performed, assessing its effect on clinical variables, pulmonary artery systolic pressure (PASP), PaO2/FiO2, and the occurrence of complications. Results In 12 patients with PE treated with catheter-directed therapy, we observed a mean increase of the PaO2/FiO2 of 62 mm Hg (p = 0.013), as well mean reduction in the PASP of 13 mm Hg (p < 0.001), as can be observed in the figure. As complications, there was one case of hemoptysis, and two of hemolysis, with an in-hospital mortality of 16.7%. Conclusion Catheter-directed therapy in patients with high or intermediate-high risk PE is a feasible option when there are contraindications for thrombolysis or there is a high bleeding risk. It has been shown to improve surrogate endpoints as PASP and right to left ventricle ratio in other studies, although data on mortality from a randomized trial is lacking. Abstract Figure. Gardner-Altman plots.

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

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.

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.

scholarly journals Reperfusion Treatment for Acute Pulmonary Embolism

2018 ◽  
Vol 38 (02) ◽  
pp. 98-105 ◽  
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.

scholarly journals Tenecteplase in Pulmonary Embolism Patients: A Meta-Analysis and Systematic Review

2021 ◽  
Author(s):  
Zhu Zhang ◽  
Linfeng Xi ◽  
Shuai Zhang ◽  
Yunxia Zhang ◽  
Guohui Fan ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Bleeding Risk ◽  
Effect Model ◽  
High Bleeding Risk

Abstract OBJECTIVE: To assess the efficacy and safety of tenecteplase in patients with pulmonary embolism (PE). METHODS: We completed the literature search on May 31, 2021 using PubMed, EMBASE and the Web of Science. Analyses were conducted according to PE risk stratification, study design and duration of follow-up. The pooled risk ratios (RRs) and its 95% confident intervals (CIs) for death and major bleeding were calculated using a random-effect model.RESULTS: A total of six studies, with four randomized controlled trials (RCTs) and two cohort studies, were included in this study out of the 160 studies retrieved. For patients with high-risk PE, tenecteplase increased 30-day survival rate (16% vs 6%; P=0.005) and did not increase the incidence of bleeding (6% vs 5%; P=0.73). For patients with intermediate-risk PE, four RCTs suggested that tenecteplase reduced right ventricular insufficiency at 24h early in the onset and the incidence of hemodynamic failure without affecting mortality in a short/long-term [<30 days RR=0.83, 95% CI (0.47, 1.46);≥30 days RR=1.04, 95% CI (0.88, 1.22)]. However, tenecteplase was associated with high bleeding risk [<30 days RR=1.79, 95% CI (1.61, 2.00); ≥30 days RR=1.28, 95% CI (0.62, 2.64)].CONCLUSIONS: Tenecteplase may represent a promising candidate for patients with intermediate/high risk PE. Furthermore, tenecteplase may be preferable in the COVID-19 pandemic due to its all-at-once administration.

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

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.

Pulmonary embolism: update on management and controversies

BMJ ◽  
2020 ◽  
pp. m2177 ◽  
Author(s):  
Lisa Duffett ◽  
Lana A Castellucci ◽  
Melissa A Forgie
Keyword(s):  
Pulmonary Embolism ◽  
Risk Factor ◽  
Venous Thromboembolism ◽  
Recurrent Events ◽  
Vitamin K Antagonists ◽  
Chronic Thromboembolic Pulmonary Hypertension ◽  
Therapeutic Options ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Increased Risk

ABSTRACTPulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.

scholarly journals The impact of a multi-specialty team for high risk pulmonary embolism on resident and fellow education

2018 ◽  
Vol 23 (4) ◽  
pp. 372-376 ◽  
Author(s):  
Ayman Elbadawi ◽  
Colin Wright ◽  
Dhwani Patel ◽  
Yu Lin Chen ◽  
Justin Mazzillo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Physician Education ◽  
Systemic Thrombolysis ◽  
Large Institution ◽  
Before And After ◽  
Response Team ◽  
Surgical Embolectomy ◽  
Physical Exam Finding ◽  
The Impact

The impact of the Pulmonary Embolism Response Team (PERT) model on trainee physician education and autonomy over the management of high risk pulmonary embolism (PE) is unknown. A resident and fellow questionnaire was administered 1 year after PERT implementation. A total of 122 physicians were surveyed, and 73 responded. Even after 12 months of interacting with the PERT consultative service, and having formal instruction in high risk PE management, 51% and 49% of respondents underestimated the true 3-month mortality for sub-massive and massive PE, respectively, and 44% were unaware of a common physical exam finding in patients with PE. Comparing before and after PERT implementation, physicians perceived enhanced confidence in identifying ( p<0.001), and managing ( p=0.003) sub-massive/massive PE, enhanced confidence in treating patients appropriately with systemic thrombolysis ( p=0.04), and increased knowledge of indications for systemic thrombolysis and surgical embolectomy ( p=0.043 and p<0.001, respectively). Respondents self-reported an increased fund of knowledge of high risk PE pathophysiology (77%), and the perception that a multi-disciplinary team improves the care of patients with high risk PE (89%). Seventy-one percent of respondents favored broad implementation of a PERT similar to an acute myocardial infarction team. Overall, trainee physicians at a large institution perceived an enhanced educational experience while managing PE following PERT implementation, believing the team concept is better for patient care.

scholarly journals Rationale for catheter-based therapies in acute pulmonary embolism

2019 ◽  
Vol 21 (Supplement_I) ◽  
pp. I16-I22 ◽  
Author(s):  
M A de Winter ◽  
G J Vlachojannis ◽  
D Ruigrok ◽  
M Nijkeuter ◽  
A O Kraaijeveld
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Early Stage ◽  
Bleeding Risk ◽  
Bleeding Complications ◽  
Common Disease ◽  
Timely Initiation ◽  
Promising Alternative ◽  
Early Reperfusion ◽  
Systemic Thrombolysis

Abstract Pulmonary embolism (PE) is a common disease resulting in significant morbidity and mortality. High-risk features of PE are hypotension or shock, and early reperfusion is warranted to unload the strained right ventricle and improve clinical outcomes. Currently, systemic thrombolysis (ST) is the standard of care but is associated with bleeding complications. Catheter-based therapies (CDT) have emerged as a promising alternative having demonstrated to be equally effective while having a lower risk of bleeding. Several CDT are currently available, some combining mechanical properties with low-dose thrombolytics. Recent guidelines suggest that CDT may be considered in patients with high-risk PE who have high bleeding risk, after failed ST, or in patients with rapid haemodynamic deterioration as bail-out before ST can be effective, depending on local availability and expertise. In haemodynamically stable patients with right ventricular (RV) dysfunction (intermediate-risk PE), CDT may be considered if clinical deterioration occurs after starting anticoagulation and relative contraindications for ST due to bleeding risk exist. Decision on treatment modality should follow a risk-benefit analysis on a case by case base, weighing the risk of PE-related complications; i.e. haemodynamic deterioration vs. bleeding. As timely initiation of treatment is warranted to prevent early mortality, bleeding risk factors should be assessed at an early stage in all patients with acute PE and signs of RV dysfunction. To ensure optimal management of complex cases of PE and assess a potential CDT strategy, a multidisciplinary approach is recommended. A dedicated Pulmonary Embolism Response Team may optimize this process.

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