Acute Submassive Pulmonary Embolism Research Articles

Percutaneous Pulmonary Thrombectomy Beyond Acute Pulmonary Embolism: Removing Organized Thrombus in Subacute Massive Pulmonary Embolism.

Mechanical thrombectomy using a thromboaspiration catheter can be an effective alternative in the treatment of subacute pulmonary embolism.

Evaluation of the incremental diagnostic value of the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) in submassive acute pulmonary embolism

Evaluation of the incremental diagnostic value of the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) in submassive acute pulmonary embolism

Safety and efficacy of clot-dissolving therapies for submassive pulmonary embolism: A network meta-analysis of randomized controlled trials

BackgroundAcute pulmonary embolism (PE) is a serious condition that needs quick and effective treatment. Anticoagulation therapy is the usual care for most PE patients but may not work well for higher-risk ones. Thrombolysis breaks the clot and improves blood flow. It can be given systemically or locally. Ultrasound-assisted catheter-directed thrombolysis (USAT) is a new technique that boosts clot-busting drugs. This network meta-analysis compares death, bleeding, and benefits of four treatments in acute submassive PE. MethodsWe comprehensively searched relevant databases up to July 2023 for RCTs. The outcomes encompassed all-cause mortality, major and minor bleeding, PE recurrence, and hospital stay duration. Bayesian network meta-analysis computed odds ratios (OR) and 95 % CI estimates. ResultsIn this network meta-analysis of 23 RCTs involving 2521 PE patients, we found that SCDT had the most favorable performance for mortality, as it had the lowest odds ratio (OR) among the four interventions (OR 5.41e−42; 95 % CI, 5.68e−97, 1.37e−07). USAT had the worst performance for major bleeding, as it had the highest OR among the four interventions (OR 4.73e+04; 95 % CI, 1.65, 9.16e+13). SCDT also had the best performance for minor bleeding, as it had the lowest OR among the four interventions (OR 5.68e−11; 95 % CI, 4.97e−25, 0.386). ConclusionOur meta-analysis suggests that SCDT is the most effective treatment intervention in improving the risks of All-cause mortality and bleeding. Thrombolytic therapy helps in improving endpoints including the risk of PE recurrence and the duration of hospital stay.

Diuretics versus volume expansion for acute pulmonary embolism: a systematic review and meta-analysis

Abstract Background/Introduction The potential benefit of diuretics over volume expansion in patients with acute submassive pulmonary embolism with right ventricle dysfunction is controversial. Purpose This study aims to compare the effects of diuretic therapy versus volume expansion in patients hospitalized for pulmonary embolism with right ventricle dysfunction. Methods We performed a systematic review and meta-analysis of studies comparing diuretics and volume expansion for acute submassive pulmonary embolism. PubMed, Embase, and Cochrane databases were searched up to January 20, 2023. Data were extracted from published reports and quality assessment was performed per Cochrane recommendations. Review Manager 5.1 was used for statistical analysis. A random-effects model was used to calculate a pooled effect size and 95% confidence interval. Results Three studies and 176 patients were included. Follow-up ranged from 2 to 30 days. The mean age was 67.5 ± 17.5 years and 52.3% were female. There were no differences between groups regarding the 24h-variation of heart rate (MD -5.98, 95% CI -14.41 to 2.46 beats/min, P = 0.17; Fig. 1A) and systolic blood pressure (MD 9.68, 95% CI -2.94 to 22.30 mmHg, P = 0.13; Fig. 1B). Diuretic therapy was associated with a faster normalisation of BNP (MD -38.38, 95% CI -60.51 to -16.24 hours, P = 0.0007; Fig. 2A). In the 24h-echocardiography parameters, no difference was found in the tricuspid annular plane systolic excursion (TAPSE) (MD -0.15, 95% CI -2.04 to 1.74 mm, P = 0.87; Fig. 2B). Similarly, no significant difference in oxygen requirement, troponin normalization, and inotropic support was seen. Conclusions Compared with the volume expansion strategy, diuretic therapy was not associated with improved hemodynamic and echocardiography parameters at 24h. Prospective and more extensive randomised trials are warranted to confirm the efficacy and safety of diuretics in acute submissive pulmonary embolism with right ventricle dysfunction.

Mechanical thrombectomy is associated with shorter length of hospital stay and lower readmission rates compared with conservative therapy for acute submassive pulmonary embolism: a propensity-matched analysis.

To determine if mechanical thrombectomy (MT) for submassive pulmonary embolism (PE) positively impacts length of hospital stay (LOS), intensive care unit stay (ICU LOS), readmission rate, and in-hospital mortality compared with conservative therapy. This was a retrospective review of all patients with submassive PE who either underwent MT or conservative therapy (systemic anticoagulation and/or inferior vena cava filter) between November 2019 and October 2021. Pediatric patients (age <18) and those with low-risk and massive PEs were excluded from the study. Patient characteristics, comorbidities, vitals, laboratory values (cardiac biomarkers, hospital course, readmission rates, and in-hospital mortality) were recorded. A 2:1 propensity score match was performed on the conservative and MT cohorts based on age and the PE severity index (PESI) classification. Fischer's exact test, Pearson's χ2 test, and Student's t-tests were used to compare patient demographics, comorbidities, LOS, ICU LOS, readmission rates, and mortality rates, with statistical significance defined as P < 0.05. Additionally, a subgroup analysis based on PESI scores was assessed. After matching, 123 patients were analyzed in the study, 41 in the MT cohort and 82 in the conservative therapy cohort. There was no significant difference in patient demographics, comorbidities, or PESI classification between the cohorts, except for increased incidence of obesity in the MT cohort (P = 0.013). Patients in the MT cohort had a significantly shorter LOS compared with the conservative therapy cohort (5.37 ± 3.93 vs. 7.76 ± 9.53 days, P = 0.028). However, ICU LOS was not significantly different between the cohorts (2.34 ± 2.25 vs. 3.33 ± 4.49, P = 0.059). There was no significant difference for in-hospital mortality (7.31% vs. 12.2%, P = 0.411). Of those that were discharged from the hospital, there was significantly lower incidence of 30-day readmission in the MT cohort (5.26% vs. 26.4%, P < 0.001). A subgroup analysis did not demonstrate that the PESI score had a significant impact on LOS, ICU LOS, readmission, or in-hospital mortality rates. MT for submassive PE can reduce the total LOS and 30-day readmission rates compared with conservative therapy. However, in-hospital mortality and ICU LOS were not significantly different between the two groups.

Treatment of acute sub-massive pulmonary embolism with balloon angioplasty and thrombolysis simultaneously

Background: Acute sub-massive pulmonary embolism is a common clinical condition, and it is associated with high mortality and morbidity. This condition is commonly associated with various co-morbidities and clinical circumstances. Methods: This is a case report series of 4 patients, wherein the thrombolysis and balloon angioplasty was performed simultaneously using a Cordis 6F diagnostic catheter and later exchanged with a 6F guide catheter in the respective pulmonary artery when a larger balloon was required. Results: All these four patients achieved successful revascularization of the respective pulmonary artery. One patient expired 30 hours after the procedure with a significant reduction in the symptoms suddenly, which was likely a second episode of pulmonary embolism. No bleeding manifestations were observed in any of the patients. The other three patients are on follow-up. Conclusion: Simultaneous coronary balloon dilatation and thrombolysis is a useful method in the treatment of sub-massive acute pulmonary embolism. If needed, higher caliber balloons can be used for the same technique using guide catheters.

Comparison of echocardiographic pulmonary flow Doppler markers in patients with massive or submassive acute pulmonary embolism and control group: A cross-sectional study.

Computed tomography angiography (CTA) is the gold standard for the diagnosis of massive (MPE) and submassive pulmonary embolism (SMPE). Ultrasound has not been accepted as a diagnostic tool. We aim to evaluate the pattern of pulmonary Doppler echocardiography in patients with pulmonary embolism (PE). From 2020 to 2022, 30 patients with acute MPE or SMPE confirmed by CTA and normal pulmonary pressures were selected. A control group was created with 30 individuals without PE. All patients had an echocardiography Doppler study of the pulmonary flow with a focus on early systolic notching (ESN), McConnell's (MC) sign, Right ventricular outflow tract velocity time integral (RVOTVTI), segmental thickness variability (STV), right ventricular end-diastolic diameter (RVEDD), tricuspid regurgitation (TR) gradient, pulmonary artery pressure (PAP), and acceleration (AT) or ejection time (ET). ESN was identified in 96.6% of PE patients and 0% of the control group (p < 0.001). In comparison with the control group, STV (p < 0.001), RVOT VTI (p < 0.001), ET (p = 0.04), and AT (p < 0.001) values were lower in patients with PE while RVEDD, TR gradient, PAP, ESN, MC sign, and d-shape were higher (p < 0.001). Identification of the ESN pattern and AT/ET < 0.4 showed excellent predictive ability for MPE and SMPE with a sensitivity of 97.0% and 100%, specificity of 99.0% and 97%, and an area under the ROC curve of 0.967 (95% CI 0.914-1.00) and 0.933 (95% CI 0.844-1.00), respectively. Doppler echocardiography with particular attention to ESN, may be a suitable noninvasive method for the diagnosis of MPE and SMPE. Further studies with more sample sizes are needed to confirm its diagnostic benefit.

Abstract No. 500 Safety and Clinical Outcomes of the Inari FlowTriever Device for Aspiration Thrombectomy in Patients with Acute Submassive and Massive Pulmonary Embolism: A Single-Arm, Retrospective Review

Abstract No. 500 Safety and Clinical Outcomes of the Inari FlowTriever Device for Aspiration Thrombectomy in Patients with Acute Submassive and Massive Pulmonary Embolism: A Single-Arm, Retrospective Review

Abstract No. 67 Time to Mechanical Thrombectomy Does Not Impact In-Hospital Outcomes for Acute Submassive Pulmonary Embolism: A Retrospective Cohort Study

Abstract No. 67 Time to Mechanical Thrombectomy Does Not Impact In-Hospital Outcomes for Acute Submassive Pulmonary Embolism: A Retrospective Cohort Study

Subakutna masivna plućna tromboembolija (PTE) - komparativni prikaz

Introduction: Subacute massive pulmonary embolism is a potentially fatal condition that can manifest in various clinical ways in a young patient , from mild and nonspecific to lethal. The incidence of pulmonary embolism in the younger population should not be overlooked, whether it involves individuals with certain risk factors, either genetic or acquired, or individuals with unidentified risk factors. Case Presentation: We are presenting two young patients, aged 35 and 37, who had a protracted course of disease and clinical manifestations at least 15 days before admission. The first patient had nonspecific pains and sensations in the chest area and coughed up blood on two occasions. The day before admission, he had an intense one-hour swimming workout. The second patient had rapid fatigue and choking, which led to an echocardiogram of the heart and a treadmill test that was terminated at the second level due to poor condition , as stated by the patient himself. He came in due to intense pain in the epigastrium, preceded by a loss of consciousness. In both patients, a diagnosis of massive PTE was made: the first by Multi-Slice Computed Tomography of the pulmonary artery (MSCTPA) and the second by clinical autopsy. The first patient received thrombolytic therapy and was discharged with NO-ACs (Apixaban) after 10 days of hospitalization. Conclusion: It is always necessary to keep in mind the possibility of PTE, even in younger patients and in cases with subtle clinical presentations, even without identified predisposing factors.

Continuous mechanical aspiration thrombectomy performs equally well in main versus branch pulmonary emboli: A subgroup analysis of the EXTRACT-PE trial.

The EXTRACT-PE trial evaluated the safety and performance of the Indigo Aspiration System (PenumbraInc.) with an 8F continuous mechanical aspiration thrombectomy system for the treatment of pulmonary embolism (PE). This subgroup analysis evaluates performance outcomes of patients with main pulmonary artery (PA) emboli versus discrete unilateral or bilateral PA emboli without main PA involvement. The EXTRACT-PE trial was a prospective, single-arm, multicenter trial that enrolled 119 patients with acute submassive PE. Emboli location was collected at the time of enrollment, CT obstruction was measured and assessed by a Core Lab, and patients were grouped on whether emboli involved the main PA (with or without branch vessels) or not (branch vessels alone). Procedural device time, changes in the right ventricle to left ventricle (RV/LV) ratio, and systolic PA pressure from pre-and posttreatment were compared between the two groups. Out of the 119 patients enrolled, 118 had core lab-assessed clot locations. Forty-five(38.1%) had emboli that involved the main PA and 73 (61.9%) had only branch emboli. No significant difference was observed between these groups for 30-day mortality, procedural device time, changes in RV/LV ratio, reduction in CT Obstruction Index, or for systolic PA pressure from pre-and posttreatment. The mean absolute reduction in clot burden was significant in both groups. Continuous mechanical aspiration thrombectomy with the 8F Indigo Aspiration System was effective at improving clinical outcomes for submassive PE patients regardless of emboli location, and clot burden was significantly reduced in both groups.

Comparison of Efficacy and Safety between Thrombolysis Plus Anticoagulation vs. Anticoagulation Alone for the Treatment of Acute Submassive Pulmonary Embolism: A Systematic Review and Meta-analysis.

The objective of this study is to compare the efficacy and safety of thrombolysis plus anticoagulant therapy vs. anticoagulant therapy alone in acute submassive pulmonary embolism (PE). The PubMed, Embase, and Cochrane Library databases were searched for randomized clinical trials comparing thrombolytic therapy and anticoagulation vs. anticoagulation alone in acute submassive PE patients from 1 Jan 1980 to 20 Jan 2021, with no drug or dose restrictions. Data on upgraded treatment of clinical deterioration, all-cause mortality, PE recurrence and bleeding events were extracted and analyzed using Revman 5.3 software. A total of 10 randomized controlled trials involving 1871 patients were included in the study after screening. In terms of efficacy, thrombolysis combined with anticoagulant therapy reduced the need for upgrading treatment (3.6 vs. 10.9%, risk ratio (RR) 0.36, 95% confidence interval (CI) 0.24- 0.54, p<0.00001) and PE recurrence (0.8 vs. 2.9%, RR 0.33, 95% CI 0.16-0.69, p=0.003) in patients with acute submassive PE. Compared with anticoagulant therapy alone, the concomitant use of thrombolysis was associated with lower all-cause mortality (1.3 vs. 3.0%, RR 0.47, 95% CI 0.26-0.87, p=0.02), but it increased minor bleeding rate (31.4 vs. 8.4%, RR 3.71, 95% CI 2.82-4.88, p<0.0001) and major bleeding rate (8.8 vs. 2.6%, RR 3.35, 95%CI 2.03-5.54, p<0.0001). The use of thrombolysis plus anticoagulant therapy in acute submassive PE was negatively associated with patients requiring escalation of treatment, PE recurrence, and all-cause mortality, but it was positively associated with bleeding.

PULMONARY HYPERTENSION FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) PLACEMENT DUE TO NEUROHORMONAL VASOACTIVE CAUSES

PULMONARY HYPERTENSION FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS) PLACEMENT DUE TO NEUROHORMONAL VASOACTIVE CAUSES

Unplanned 30-Day Readmissions after Management of Submassive and Massive Acute Pulmonary Embolism: Catheter-Directed versus Systemic Thrombolysis

PurposeTo compare 30-day readmission and in-hospital outcomes from the Nationwide Readmissions Database (NRD) for catheter-directed thrombolysis (CDT) versus systemic intravenous thrombolysis (IVT) as treatments for acute submassive or massive pulmonary embolism (PE). Materials and MethodsThe NRD was queried from 2016 to 2019 for adult patients with nonseptic acute PE who underwent IVT or CDT. Massive PE was distinguished from submassive PE if patients had concurrent International Classification of Diseases (ICD-10) codes corresponding to mechanical ventilation, vasopressors, or shock. Propensity score–matched analysis was conducted to infer the association of CDT versus IVT in unplanned 30-day readmissions, nonroutine discharge, gastrointestinal bleeding (GIB), and intracranial hemorrhage (ICH). These results are demonstrated as average treatment effects (ATEs) of IVT compared with those of CDT. ResultsA total of 37,116 patients with acute PE were studied; 18,702 (50.3%) underwent CDT, and 18,414 (49.7%) underwent IVT. A total of 2,083 (11.1%) and 3,423 (18.6%) were massive PEs in the 2 groups, respectively (P < .001). The ATE of IVT was higher than that of CDT regarding unplanned 30-day readmissions (ATE, 0.019; P < .001), GIB (ATE, 0.012; P < .001), ICH (ATE, 0.003; P = .017), and nonroutine discharge (ATE, 0.022; P = .006). The subgroup analysis of patients with submassive PE demonstrated that IVT had a higher ATE regarding unplanned 30-day readmission (ATE, 0.028; P < .001), GIB (ATE, 0.008; P = .003), ICH (ATE, 0.002; P = .035), and nonroutine discharge (ATE, 0.019; P = .022) than CDT. ConclusionsCDT had a lower likelihood of unplanned 30-day readmissions, including when stratified by a submassive PE subtype. Additionally, adverse events, including ICH and GIB, were more likely among patients who received IVT than among those who received CDT.

Abstract No. 275 Unplanned 30-day readmissions and in-hospital outcomes for the management of submassive and massive acute pulmonary embolism: catheter-directed versus systemic thrombolysis

To compare catheter-directed thrombolysis (CDT) to systemic intravenous thrombolysis (IVT) for acute submassive or massive pulmonary embolism with respect to 30-day readmission and in-hospital outcomes utilizing the Nationwide Readmission Database

Abstract No. 276 Mechanical thrombectomy is associated with shorter length of hospital stay and lower readmission rates compared with conservative therapy for acute, submassive pulmonary embolism: a propensity matched analysis

The role of mechanical thrombectomy (MT) for acute sub-massive pulmonary embolism (PE) has not been well studied. Therefore, the purpose of this study was to determine if MT for sub-massive PE positively impacts length of hospital stay (LOS), ICU stay (ICU LOS), readmission rate, and in-hospital mortality when compared with conservative therapy.

Ultrasound-assisted catheter-directed thrombolysis versus anticoagulation alone for management of submassive pulmonary embolism

BackgroundPatients with submassive pulmonary embolism (PE) are vulnerable to sudden deterioration, recurrent PE, and progression to pulmonary hypertension and chronic right ventricular (RV) dysfunction. Previous studies have suggested a clinical benefit of using ultrasound-assisted catheter-directed thrombolysis (USCDT) to invasively manage patients with submassive PE. However, there is sparse data comparing the clinical outcomes of these patients when treated with USCDT versus anticoagulation (AC) alone. We sought to compare the outcomes of USCDT versus AC alone in the management of submassive PE. Methods192 consecutive patients who underwent USCDT for submassive PE between January 2013 and February 2019 were identified. ICD9/ICD10 codes were used to detect 2554 patients diagnosed with PE who did not undergo thrombolysis. Propensity matching identified 192 patients with acute PE treated with AC alone. Clinical outcomes were compared between the two groups. Baseline demographics, laboratory values, and pulmonary embolism severity index scores were similar between the two cohorts. ResultsThere was a significant reduction in mean systolic pulmonary artery pressure (sPAP) in the USCDT group compared to the AC group (∆11 vs ∆3.9 mmHg, p < 0.001). There was significant improvement in proportion of RV dysfunction in all patients, but the difference was larger in the USCDT group (∆43.3% vs ∆17.3%, p < 0.001). Patients who underwent USCDT had lower 30-day (4.3% vs 10.5%, p = 0.03), 90-day (5.5% vs 12.4%, p = 0.03), and 1-year mortality (6.2% vs 14.2%, p = 0.03). ConclusionsIn patients with acute submassive PE, USCDT was associated with improved 30-day, 90-day, and 1 year mortality as compared to AC alone. USCDT also improved RV function and reduced sPAP to a greater degree than AC alone. Further studies are needed to verify these results in both short- and long-term outcomes.

Initial experience and early outcomes of the management of acute pulmonary embolism using the FlowTriever mechanical thrombectomy device.

Submassive and massive pulmonary embolism is associated with a high risk of complications. We aimed to evaluate our initial experience with a mechanical thrombectomy device in the management of these patients. A single-center, retrospective study was performed in patients with acute submassive and massive pulmonary embolism treated with the FlowTriever device (Inari Medical, Irvine, CA, USA) between June 2019 and November 2020. Clinical and technical parameters were analyzed during the hospitalization and at 30- and 180-days after the procedure. Fourteen patients were evaluated with a median (IQR) age of 60 (50-69) years and 64% were male. All had right heart strain as the main indication for thrombectomy. The procedure duration and fluoroscopic time was 52 (37-89) and 13 (9-24) minutes, respectively. There was 100% technical success, and the pulmonary arterial pressure went from 60 (48-65) mmHg to 40 (34-47) mmHg. Thrombolysis was used in two patients and nine patients required intensive care. 100% experienced improvement in symptoms at the time of discharge. There were no device-related complications, major bleeding events, myocardial infarctions, or deaths. Preprocedural hemoglobin was 13 (12-15) g/dL, and predischarge was 12 (10-13) g/dL. Overall postprocedural length of stay was three (2-6) days. All the patients were discharged with oral anticoagulation. There were no device-related complications or recurrence of embolism at 30 and 180 days. The mechanical thrombectomy device for submassive and massive pulmonary embolism is promising and appears a safe and effective procedure with 100% technical success, no complications, short intensive care requirement/stay, and good early clinical outcomes.

Interventional Reperfusion Strategies for Acute Pulmonary Embolism

Acute pulmonary embolism (APE) is a common, potentially life-threatening cardiovascular emergency, and represents the third leading cause of cardiovascular mortality after myocardial infarction and stroke. Risk stratification is important to guide the management of APE, as an early reperfusion strategy is associated with improved clinical outcomes in specific high-risk conditions. Pulmonary artery reperfusion is commonly achieved by systemic intravenous administration of thrombolytic drugs, but catheter-directed thrombolysis (CDThr) and interventional techniques of catheter-based embolectomy provide novel therapeutic approaches with an improved risk-benefit ratio. Future trials will help to determine when to use these different devices in massive or sub-massive APE, and which patient population is likely to benefit from interventional treatment.

Society for Vascular Medicine Abstracts presented at the SVM 2021 Virtual Scientific Sessions

Background: Right heart thrombi and thrombi in transit across a patent foramen ovale (PFO) are uncommonly seen in patients with pulmonary embolism (PE) and are associated with high risk of adverse outcomes. We present a case of bi-atrial thrombi and thrombus in transit in a patient with acute submassive PE. Methods/Case Description/Results: A 31-year-old male with no significant past medical history presented with 8 days of dyspnea on exertion and pleuritic chest pain. Computed tomography angiography showed large volume of bilateral PE with right ventricular (RV) strain and right atrial (RA) thrombus. He was hemodynamically stable. Cardiac biomarkers were elevated. COVID testing was negative. Pulmonary embolism response team (PERT) was activated. Transthoracic echocardiogram revealed severely dilated RV with severely reduced function. A mobile mass was seen in the RA, possibly anchored to the interatrial septum. An emergent transesophageal echocardiogram showed mobile thrombus within both atria and thrombus in transit through a PFO. After multidisciplinary PERT discussion, involving the patient and his family, decision was made to proceed with a surgical approach, including pulmonary artery and bi-atrial embolectomy, and PFO closure. Post-surgical recovery was uneventful, and he was discharged on aspirin and apixaban on postoperative day 6. Follow up TTE 4 weeks after discharge showed recovered RV size and function. The patient is back to normal functional status. Conclusion: Combined biatrial thrombi and thrombi in transit are rare in patients with PE. Multidisciplinary approach to such patients, taking into account risks and benefits of each treatment approach, and patient preferences, is of paramount importance to achieve optimal patient outcome..