THE CLOT THICKENS: AN OBSERVATIONAL RETROSPECTIVE ANALYSIS OF STANDARD OF CARE VS CATHETER-DIRECTED THERAPY FOR SADDLE PULMONARY EMBOLISM

Abstract

SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Catheter directed therapy (CDT) has garnered increased interest in the treatment of submassive pulmonary embolism (PE) given its potential for rapidly reducing right heart strain (RHS) and clot burden. Our aim was to compare outcomes between standard of care (SC) and CDT in the management of submassive saddle PE. METHODS: In this retrospective analysis, patient chart review was performed on patients diagnosed with a submassive PE and subsequently treated with either SC or CDT. Submassive PE was characterized as those with evidence of RHS on either echocardiogram or CT, but without sustained hypotension (systolic BP <90mmHg). SC entailed treatment with systemic anticoagulation. Treatment with CDT involved a 2mg alteplase (tPA) bolus into each branch of the pulmonary artery (PA) followed by an infusion of the same for a maximum of 24 hours. tPA was discontinued when the mean PA pressure fell below 25mmHg with subsequent transition to systemic anticoagulation. Data was analyzed via chi-square analysis or Mann-Whitney U test for categorical or continuous variables, respectively, using SAS and GraphPad version 8. Statistical significance was determined with p < 0.05 RESULTS: A total of 39 patients diagnosed with saddle PE were treated with either CDT (n = 16) or SC (n = 23) in the period of August 2017 to December 2019. Mean Pulmonary Embolism Severity Index (PESI) score was 112.62 ± 55.61 vs 89.87 ± 26.05 in the CDT vs SC groups, respectively (p = 0.44). 5/16 patients in the CDT arm, compared to 1/23, presented with syncope (p = 0.02). PA pressure at presentation was 62.1 ± 16.14 mmHg and 55.63 ± 11.33 mmHg in the CDT vs SC groups, respectively (p = 0.44). 87.5% in the CDT arm demonstrated right heart strain by ECHO, versus 60.86% in SC arm (p = 0.07). In terms of outcomes, mean length of stay was 5.88 days in the CDT group vs 5 days in the SC group (p = 0.14). No inpatient deaths occurred in either group. Mean PA pressure measured at 3 months in the CDT arm was 26.86 ± 6.59 mmHg vs. 28.38 ± 10.24 mmHg in the CDT vs SC groups, respectively (p = 0.96), while mortality was 0% and 6.67%, respectively (p = 0.46). CONCLUSIONS: There was no statistical significance in both mortality and inpatient survival in patients treated with CDT vs SC. The same was demonstrated in terms of presentation and parameters of severity between the CDT and SC arms, aside from an increased incidence of syncope on presentation in the CDT arm. A limitation of our study was the small cohort of patients involved, which prevents extrapolation of data in a generalized manner. A prospective, randomized trial is required to confirm our results. CLINICAL IMPLICATIONS: Saddle PE tends to have the connotation of requiring more aggressive intervention, such as CDT. Although CDT has been shown to be a safe and effective option, it may not necessarily be the best strategy. Clinical judgment, however, should ultimately prevail in guiding therapy. DISCLOSURES: No relevant relationships by Timmy Li, source=Web Response No relevant relationships by Akhilesh Mahajan, source=Web Response No relevant relationships by Anu Menon, source=Web Response No relevant relationships by Bushra Mina, source=Web Response No relevant relationships by Varun Shah, source=Web Response No relevant relationships by Muhammad Shoaib, source=Web Response