105 Ultrasound-Enhanced Catheter-Directed Thrombolysis for Patients With Massive and Submassive Pulmonary Embolism Presenting to the Emergency Department

Abstract

Venous thromboembolism (VTE) affects 1 in 1000 population in the United States with a 3-, 6-, and 12-month mortality rate of 23.2%, 30.2% and 37.1%. The rate of recurrent pulmonary embolism (PE) within 90 days in patients with VTE is 12%. Most PE’s are diagnosed in the ED. Risk stratification into massive, sub massive and nonmassive is done based on clinical presentation and clot burden. Catheter directed thrombolysis (CDT) has been one of the newer strategies for management of massive PE (Class IIa) and has also been recommended by AHA for patients with submassive PE (Class IIb). Ultrasound-enhanced (UE) CDT combines ultrasonic clot destruction with local thrombolysis and has been shown to reduce the RV/LV ratio and clot burden. The objective was to evaluate the overall effectiveness of an ED-based protocol including UE CDT in the management of massive and submassive PEs. A retrospective cohort of consecutive patients with suspected massive or submassive PE presenting to the ED between 2010-2015, diagnosed utilizing a clinical protocol based on POC ultrasound were included in the study. Demographic data along with mortality rate (primary endpoint), echocardiographic RV dilation (secondary endpoint) and complications were abstracted. The Pulmonary Embolism Severity Index (PESI) score was used to grade PE severity. Mortality from our study cohort was compared to the historic cohort from the PESI study. A total of 84 patients with a mean age of 58.7 years (SD ± 14.4) were included, with 54% male and 69% African Americans. The mean length of stay was 8.4 (SD ± 6.9) days with an overall inpatient mortality of 7.14%. This was statistically significant when compared to the PESI Study (23.2%, 19.8-27.0, p= 0.001), where standard of care was used (Table). Echocardiography done post-procedure displayed improvement in most PESI classes compared to baseline (Figure). Utilization of an ED-based diagnostic algorithm that includes UE CDT improved the outcomes in the patients with higher PESI scores.TableMortality Percentages Within PESI ClassPESI Risk ClassUE CDT Study MortalityN=84 (%, 95% CI)PESI Study Mortality at 3 months N=525 (%, 95% CI)Overall6/84 (7.1%), 1.3 - 10.7122/525 (23.2%), 19.8-27.0Class I0/13 (0%), NA0/48 (0%), 0-7.4Class II2/25 (8%), 0.0 - 4.89/121 (7.4%), 4.0-13.5Class III1/19 (5.3%), 0.0 - 3.025/139 (18.0%), 12.5-25.2Class IV1/12 (8.3%), 0.0 - 3.033/115 (28.7%), 21.1-37.5Class V2/15 (13.3%), 0.0 - 4.855/102 (53.9%), 44.3-63.3 Open table in a new tab