Abstract
Objectives We sought to assess the technical and clinical feasibility of continuous aspiration catheter-directed mechanical thrombectomy (CDT) in patients with high- or intermediate-high-risk pulmonary embolism (PE). Methods and Results Fourteen patients (eight women and six men; age range: 29–71 years) with high- or intermediate-high-risk PE and contraindications to or ineffective systemic thrombolysis were prospectively enrolled between October 2018 and February 2020. The Indigo Mechanical Thrombectomy System (Penumbra, Inc., Alameda, California) was used as CDT device. Low-dose local thrombolysis (alteplase, 3–12 mg) was additionally applied in three patients. Technical and procedural success was achieved in 14 patients (100%). Complete or nearly complete clearance of pulmonary arteries was achieved in nine patients (64.3%), whereas partial clearance was achieved in five (35.7%). A significant improvement in the pre- and postprocedural patients' clinical status was observed in the following fields (median; interquartile range): heart rate (110; 100–120/min vs. 85; 80–90/min; p < 0.0001), systolic blood pressure (106; 90–127 mmHg vs. 123; 110–133 mmHg; p = 0.049), arterial oxygen saturation (88.5; 84.2–93% vs. 95.0; 93.8–95%, p = 0.0051), pulmonary artery systolic pressure (55; 44–66 mmHg vs. 42; 34–53 mmHg; p = 0.0015), Miller index score (21.5; 20–23 vs. 9.5; 8–13; p < 0.0001) and right ventricular/left ventricular ratio (1.3; 1.3–1.5 vs. 1.0; 0.9–1.0; p < 0.0001). No major periprocedural bleeding was detected. Conclusions CDT is a feasible and promising technique for management of high- or intermediate-high-risk PE to decrease thrombus burden, reduce right heart strain, and improve hemodynamic and clinical status. Some patients may benefit from simultaneous local low-dose thrombolytic therapy. Nevertheless, its criteria and role in CTD-managed patients require further elucidation.
Highlights
Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality and its occurrence is estimated at 39–115 cases/100000 inhabitants/year [1,2,3,4]. e presentation of PE may vary from asymptomatic or mild exertion disturbances treated with anticoagulants only to hemodynamic “obstructive” collapse and death [5]
Patients older than 18 years of age with proximal PE confirmed by computed tomography pulmonary angiography (CTPA) and symptoms onset within 14 days were eligible for enrollment in the present study. e severity of PE was categorized as low-risk, intermediate-low-risk, intermediate-high-risk, or high-risk in accordance with the guidelines of the European Society of Cardiology (ESC) [5, 15]. e precise PE patients risk stratification is presented on Figure 1. e details concerning organizing and functioning of our institutional PERT were published elsewhere [16]
5 high-risk PE patients were qualified for catheter-directed aspiration thrombectomy (CDT) on the basis of absolute contraindication to Systemic thrombolysis (ST) and refractory circulatory collapse, and 9 intermediatehigh PE patients were qualified for the CDT procedure because of coexistence of persistent right ventricular (RV) dysfunction with tachycardia heart rate (HR) ≥ 110/min, SBP
Summary
Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality and its occurrence is estimated at 39–115 cases/100000 inhabitants/year [1,2,3,4]. e presentation of PE may vary from asymptomatic or mild exertion disturbances (low-risk PE) treated with anticoagulants only to hemodynamic “obstructive” collapse and death (high-risk or massive PE) [5]. E controversy concerns especially risk stratification and treatment in intermediate-high-risk (submassive) PE patients. Systemic thrombolysis (ST) decreases mortality and improves clinical status in high-risk PE patients, but it poses higher major bleeding risk [6]. Patients in this group do not have developed features of hemodynamic instability (hypotension, the need for catecholamines, disturbances, or loss of consciousness), but they have right ventricular (RV) overload characteristics, elevated markers of necrosis, and high values of Pulmonary. Catheterdirected thrombolysis has been applied as an alternative to STand has been shown to improve RV strain It is still associated with a relatively high bleeding risk, because of usage of thrombolytic agents [14]. CDT without thrombolytic drug administration is considered to be a promising therapeutic option [12, 13]. e present study aimed to evaluate the safety and feasibility of this approach
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