Catheter-directed Intervention Research Articles

Long term recovery of right ventricular function after treatment of intermediate and high risk pulmonary emboli

IntroductionPulmonary embolism (PE) is a common and significant source of mortality and morbidity worldwide. A subset of patients with PE, particularly those who have intermediate and high risk events, are at increased risk for long-term right ventricular (RV) dysfunction; however, the impact of novel advanced therapies used for acute PE, including catheter-directed intervention, on long-term RV function remains uncertain. We sought to determine whether use of advanced therapies (catheter-directed intervention or systemic thrombolysis) is associated with improved long-term RV function. Materials and methodsRetrospective, single-center cohort study of adult (≥18 year old) patients admitted and discharged alive with a diagnosis of acute PE, who fell under the category of intermediate or high risk, with available follow-up echocardiograms at least 6 months after the index, seen at a single quaternary referral center in Los Angeles, CA between 2012 and 2021. ResultsThere were 113 patients in this study (58 (51.3 %) treated with anticoagulation alone, 12 (10.6 %) treated with systemic thrombolysis, and 43 (38.1 %) treated with catheter-directed intervention), with approximately equal gender and racial distribution. Patients treated with advanced therapies were significantly more likely to have moderate-severe RV dysfunction (100 % for those treated with thrombolysis, 88.3 % for those treated with catheter-directed intervention, vs 55.2 % for those treated with anticoagulation alone; p < 0.001). At a follow-up of about 1.5 years, patients treated with advanced therapy (systemic thrombolysis or catheter-directed intervention) were more likely to have normalization of RV function (93–100 % vs 81 % for anticoagulation alone, p = 0.04). The subgroup of patients with intermediate-risk PE was significantly more likely to have normalization of RV function (95.6 % vs 80.4 % for anticoagulation alone, p = 0.03). Use of advanced therapy was not associated with substantial short-term adverse events among patients who survived to hospital discharge. ConclusionPatients with intermediate and high risk PE were more likely to have recovery in RV function long-term if treated with catheter-directed intervention or systemic thrombolysis, as compared to anticoagulation alone, without substantial safety issues, despite having worse RV function at baseline. Further data is needed to verify this observation.

869: MORTALITY AND BLEEDING RISKS OF INTERVENTIONS FOR HIGH- AND INTERMEDIATE-RISK PULMONARY EMBOLISM

Introduction: Multiple strategies have been used to treat patients at high and intermediate risk of mortality from an acute pulmonary embolism (PE), but the most effective and safest treatment remains poorly defined. We aimed to investigate the mortality and bleeding complications in high/intermediate risk PE patients following different treatments. Methods: We searched PubMed and EMBASE databases from inception to July 2022 and included observational studies and randomized controlled trials (RCT) encompassing high and intermediate risk PE patients and comparing at least two of the following treatments: systemic thrombolysis (ST), anticoagulation only (AC), catheter-directed intervention (CDI), and surgical embolectomy (SE). The primary outcome was in-hospital mortality. The secondary outcomes were 1-year mortality, major or minor bleeding. Results: This network meta-analysis identified four RCTs and 27 observational studies involving 117,628 patients. CDI was associated with lower in-hospital mortality than ST (OR [95%CI]: 0.42 [0.32-0.55]), AC (OR [95%CI]: 0.43 [0.27-0.66]), and SE (OR [95%CI]: 0.52 [0.33-0.82]). AC was associated with higher 1-year mortality than the other strategies. AC was associated with the lowest risk of major bleeding compared to ST (OR [95%CI]: 0.46 [0.29-0.74]), CDI (OR [95%CI]: 0.61 [0.38-0.99]), and SE (OR [95%CI]: 0.44 [0.23-0.85]). Furthermore, CDI was associated with lower risks of major bleeding than ST (OR [95%CI]: 0.75 [0.58-0.96]). AC was associated with lower risks of minor bleeding than ST and CDI, whereas CDI was also associated with a lower risk of minor bleeding compared to ST. Conclusions: In patients with high/intermediate risk PE, CDI was associated with lower mortality and decreased bleeding complications compared to other treatment strategies. Further studies including randomized control studies are required to validate our findings.

Hospital procedural volume and outcomes with catheter-directed intervention for pulmonary embolism: a nationwide analysis.

There is limited data on the association between hospital catheter-directed intervention (CDI) volume and outcomes among patients with acute pulmonary embolism (PE). The Nationwide Readmissions Database years 2016-2019 was utilized to identify hospitalizations undergoing CDI for acute PE. Hospitals were divided into tertiles based on annual CDI volume; low-volume (1-3 procedures), moderate-volume (4-12 procedures) and high-volume (>12 procedures). The primary outcome was all-cause in-hospital mortality. Among 1 436 382 PE admissions, 2.6% underwent CDI; 5.6% were in low-volume, 17.3% in moderate-volume and 77.1% in high-volume hospitals. There was an inverse relationship between hospital CDI volume and in-hospital mortality (coefficient -0.344, P < 0.001). On multivariable regression analysis, hospitals with high CDI volume were associated with lower in-hospital mortality compared with hospitals with low CDI volume (adjusted odds ratio [OR] 0.71; 95% confidence interval [CI] 0.53, 0.95). Additionally, there was an inverse association between CDI volume and length of stay (LOS) (regression coefficient -0.023, 95% CI -0.027, -0.019) and cost (regression coefficient -74.6, 95% CI -98.8, -50.3). There were no differences in major bleeding and 30-day unplanned readmission rates between the three groups. In this contemporary observational analysis of PE admissions undergoing CDI, there was an inverse association between hospital CDI volume and in-hospital mortality, LOS, and cost. Major bleeding and 30-day unplanned readmission rates were similar between the three groups.

Outcomes of catheter-directed interventions in high-risk pulmonary embolism-a retrospective analysis.

BackgroundFirst‐line treatment of high‐risk pulmonary embolism with persistent hypotension and/or signs of shock is intravenous thrombolysis. However, if thrombolysis is contraindicated due to risk of serious bleeding, or if it yields insufficient effect, surgical thrombectomy or catheter‐directed intervention (CDI) plus anticoagulation is recommended. The aim of this study was to assess the outcomes of the CDI modality introduced in a tertiary referral centre in 2013.MethodsRetrospective comparison between patients treated with CDI plus anticoagulation (n = 22) and patients treated with anticoagulation only (n = 23) as used before the CDI technique was available. The main outcomes of interest were 90‐day survival and reduction of right to left ventricle diameter (RV/LV) ratio, using the Fischer's exact test and a mixed model, respectively, for statistical analysis.ResultsNinety‐day survival was 59% after CDI and 61% after anticoagulation only; P = .903. The rate of RV/LV ratio reduction was 0.4 units higher per 24 hours in the CDI group (median 2.1 pre‐treatment), than in the anticoagulation only group (median 1.3 pre‐treatment); P = .007.ConclusionIn patients with high‐risk pulmonary embolism, 90‐day survival was similar after treatment with CDI plus anticoagulation compared to anticoagulation only. The mean reduction in RV/LV ratio was larger in the CDI group. Our results support the use of CDI in selected patients, respecting the limitations and potential side effects of each technical device used.

ASE Statement on the Reintroduction of Echocardiographic Services during the COVID-19 Pandemic

• Echocardiography services have been interrupted by the COVID pandemic. • Services are being gradually reintroduced as healthcare facilities reopen. • Operational, workflow and prioritization considerations are suggested.

A case-controlled study on AngioJet rheolytic thrombectomy and catheter-directed thrombolysis in the treatment of acute lower extremity deep venous thrombosis.

Objective This study aims to compare the efficacy and safety of AngioJet rheolytic thrombectomy vs. catheter-directed thrombolysis in patients with acute lower extremity deep vein thrombosis. Methods Between the period of February 2015 and October 2016, 65 patients with documented acute lower extremity deep vein thrombosis were treated with catheter-directed intervention. These patients were divided into two groups: AngioJet group and catheter-directed thrombolysis group. Comparisons were made with regard to efficacy and safety between these two groups. Results In the AngioJet group, complete or partial thrombus removal was accomplished in 23 (72%) and 3 (9%) patients, respectively. In the catheter-directed thrombolysis group, complete or partial thrombus removal was accomplished in 27 (82%) patients and 1 (3%) patient, respectively. In the AngioJet group, the perimeter difference between the suffered limb and healthy one declined from 5.1 ± 2.3 cm to 1.4 ± 1.2 cm ( P &lt; 0.05). In the catheter-directed thrombolysis group, the perimeter difference declined from 4.7 ± 1.6 cm to 1.5 ± 0.9 cm ( P &lt; 0.05). The mean urokinase dose was 0.264 ± 0.135 million units in the AngioJet group and 1.869 ± 0.528 million units in the catheter-directed thrombolysis group ( P &lt; 0.05). The duration of thrombolysis was 4.2 ± 1.7 h in the AngioJet group and 73.6 ± 18.3 h in the catheter-directed thrombolysis group ( P &lt; 0.05). The occurrence of complications in these two groups was 19% and 18%, respectively (not significant). Conclusion AngioJet rheolytic thrombectomy is a new, safe and effective approach for treating acute lower extremity deep vein thrombosis. When compared to catheter-directed thrombolysis, this treatment provides similar success with lower urokinase dosage and shorter duration of thrombolysis.

P3852Twenty-eight-year temporal trends of treatment strategy and short-term outcomes in patients with high-risk pulmonary embolism: impact of ESC guidelines changes

Abstract Background Thrombolysis has been recommended for high-risk pulmonary embolism (PE) in ESC guidelines, used as a reference in Japan. Recently, indication of thrombolysis for acute PE has been limited with recent guideline revision. Little is known regarding trends of treatment strategy and mortality in high-risk PE patients. Purpose To clarify temporal trends of treatment strategy and short-term outcomes in high-risk PE patients. Methods A retrospective analysis of therapeutic interventions and short-term outcomes was performed for 52 consecutive high-risk PE patients including cardiac arrest. According to timing of ESC guidelines update (2000, 2008 and 2014), patients were divided into four time periods: 1992 to 2000, 2001 to 2008, 2009 to 2014, and 2015 to 2018. Results Mean age and proportion of male were not different over the period. Nosocomial case decreased from 100% to 25% (p&lt;0.01). Postoperative cases (relative contraindication for thrombolysis) included 43% of all patients. Cardiac arrest and VA-ECMO use were 42% and 21% of all patients. Any thrombolytic therapy including catheter-directed intervention showed a non-significant decrease trend (92%-87%-71%-44%, p=0.067). Temporary or retrieval IVC filter insertion showed a significant downward trend (36%-80%-54%-22%, p=0.025). The entire study 30-day mortality was 23%. There was no significant difference in 30-day mortality over the periods (14%-27%-14%-44%, p=0.303). However, major bleeding decreased significantly (71%-40%-7%-22%, p=0.004) (Table). Table 1 1992–2000 (n=14) 2001–2008 (n=15) 2009–2014 (n=14) 2015–2018 (n=9) p Age (years) 54±12 59±17 64±13 65±16 0.224 Male 29% 13% 29% 44% 0.269 Any thrombolytic therapy 92% 87% 71% 44% 0.067 Catheter-directed therapy 86% 87% 71% 0% &lt;0.01 with thrombolytics (92%) (83%) (90%) without thromboloytics (8%) (17%) (10%) Only intravenous thrombolysis 8% 7% 7% 44% 0.038 Temporary/retrieval IVC filter 36% 80% 54% 22% 0.025 ICU stay (days) 15±14 10±18 5±4 8±8 0.206 30-day mortality 14% 27% 14% 44% 0.303 Major bleeding 71% 40% 7% 22% 0.004 Conclusion The temporal analysis identified a decreased trend in any thrombolytic therapy and IVC filter insertion in high-risk PE. The study also found a decreasing trend in major bleeding.

IP279. Catheter Interventions Improve Outcomes in Patients With Intermediate-Risk Pulmonary Embolism

Acute intermediate-risk pulmonary embolism (PE), defined by evidence of right ventricular (RV) dysfunction in a normotensive patient, represents more than half of all diagnosed PEs. The natural history of intermediate-risk PE includes resolution of RV dysfunction, chronic RV dysfunction, development of chronic thromboembolic pulmonary hypertension (CTEPH), and death. RV dysfunction has been directly correlated with short-term mortality. In addition, studies have demonstrated that chronic RV dysfunction and CTEPH may correlate with the size of the perfusion defect. The mainstay of treatment in intermediate-risk PE remains anticoagulation. However, thrombolysis has previously been shown to more rapidly reduce RV dysfunction in the acute period. Recent advances in catheter-directed intervention (CDI), such as thrombus aspiration, fragmentation, and directed thrombolysis, have enabled their use in intermediate-risk PE with demonstrable safety. Understanding which patients would benefit from anticoagulation alone and which should be offered CDI could lead to a reduction in chronic RV failure and CTEPH. We retrospectively reviewed patients who presented to our institution during a 2-year period with a diagnosis of acute intermediate-risk PE. A comparison was made between those receiving medical therapy alone with therapeutic anticoagulation and those treated by CDI with either thrombolysis using the EKOS catheter (EKOS Corporation, Bothell, Wash) or percutaneous thrombectomy/aspiration using the FlowTriever device (Inari Medical, Irvine, Calif). Data collected included demographics, comorbidities, hospital and intensive care unit length of stay, major complications, 30-day mortality, resolution of RV failure, and development of CTEPH. Fifty patients were analyzed; 24 underwent CDI and 26 underwent medical management. Those who were chosen to undergo CDI had higher rates of severe RV failure (71% vs 42%; P = .05) and higher rates of central PE (96% vs 52%; P = .0008) on presentation. The 30-day mortality of the intervention group and the medical group was similar at 4.2% and 3.9%, respectively. Hospital stay and intensive care unit length of stay were also similar. Those who underwent CDI had lower rates of chronic RV failure (23% vs 50%; P = .27; Fig 1) and CTEPH (4% vs 15%; P = .35). Patients with a central PE who had CDI had a statistically significant lower rate of CTEPH development (4% vs 31%; P = .047; Fig 2). There was no difference in outcomes between those undergoing thrombolysis and those undergoing thrombectomy/aspiration. Adequately selected patients presenting with an intermediate-risk PE may benefit from CDI to prevent the development of chronic RV failure and CTEPH, especially those who have a centrally located PE on presentation.Fig 2Development of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with central pulmonary embolism (PE).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Venous thromboembolism: A clinician update.

Venous thromboembolism (VTE) is a common vascular condition. New medications are available to prevent hospital-associated VTE. Strategies are being studied to increase appropriate diagnostic testing utilization. Management of deep vein thrombosis (DVT) and pulmonary embolism (PE) has evolved with the advent of new anticoagulant options and catheter-directed intervention. In light of this, providers are commonly challenged with the decision regarding inpatient versus outpatient management. Which patients require long-term (> 3 months) anticoagulation is challenging and multiple clinical prediction models may be used to help determine the risk-benefit ratio in each patient. The management of VTE is an ongoing area of research and is rapidly evolving.

Design and rationale of a randomized trial comparing standard versus ultrasound-assisted thrombolysis for submassive pulmonary embolism.

Catheter-directed interventions for the treatment of patients with submassive pulmonary embolism (sPE) have shown promise in rapidly improving right-sided heart strain and preventing decompensation to massive pulmonary embolism. Among various catheter interventions, ultrasound-assisted thrombolysis (USAT) has attracted interest as potentially having more efficient lytic effect that could achieve thrombolysis faster and with a reduced lytic dose. However, based on clinical evidence, it is unclear whether USAT is superior to standard catheter-directed thrombolysis (SCDT). We herein describe the study design of the Standard vs UltrasouNd-assiSted CathEter Thrombolysis for Submassive Pulmonary Embolism (SUNSET sPE) trial, an ongoing randomized clinical trial designed to address this question. Adults with sPE presenting or referred to our institution are considered for enrollment in the trial. At the discretion of the treatment team, all patients undergo a catheter-directed intervention plus concomitant therapeutic anticoagulation. Participants are randomized 1:1 to a USAT catheter or an SCDT catheter. Study assessors are blinded to treatment group. The primary outcome is clearance of pulmonary thrombus burden, assessed by postprocedure computed tomography angiography. Secondary outcomes include resolution of right ventricular strain by echocardiography; improvement in pulmonary artery pressures; and 3- and 12-month improvement in echocardiographic, functional capacity, and quality of life measures. The study is powered to detect a 50% improvement in pulmonary artery thrombus clearance. Our enrollment target is 40 patients per treatment arm. SUNSET sPE is an ongoing randomized, head-to-head, single-blinded clinical trial with the goal of assessing whether USAT results in superior thrombus clearance compared with SCDT in patients with sPE. We expect the results ofour study to inform future guidelines on choice of thrombolysis modality in this population of challenging patients.

“Radial” approach to high risk pulmonary embolism – transcubital catheter directed intervention as a first-line therapy in patients with clinically massive and submassive pulmonary embolism.

2016;11(3-4):133. VII. nacionalni sastanak o kardiovaskularnim intervencijama s međunarodnim sudjelovanjem VI. sastanak intervencijskih kardioloskih medicinskih sestara i tehnicara Goal: Despite the guidelines, more than two-thirds of patients with massive/high risk pulmonary embolism (PE) do not receive thrombolytic therapy1,2. Submassive/intermediate risk PE, as defined by right ventricular failure and/or NT-proBNP/troponin elevation, which can result in life-threatening deterioration/sequel is treated with thrombolytic therapy even less frequently. The main reason, that thrombolytics are used infrequently despite the potential clinical benefit of rapid clot lysis, is respect for significant bleeding complications, since nonpathologic thrombi are also lysed. The reluctance of majority of treating physicians to actually use thrombolytic therapy in everyday praxis persist and is matched only by zeal to publish successfully treated cases by minority of interventional colleagues. “Radial” – transcubital approach to high risk pulmonary embolism and subsequent catheter directed intervention (CDI) is proposed as a realistic alternative to both routinely used heparin therapy and surgical embolectomy, that can with modifications even be used in the case of contraindications for thrombolytic therapy. The goal of this presentation is to present a real-life center experience of the feasibility and safety of CDI including protocol for transcubital CDI as a first-line therapy in patients with clinically massive/high risk and submassive/intermediate risk PE.

Improved early right ventricular function recovery but increased complications with catheter-directed interventions compared with anticoagulation alone for submassive pulmonary embolism.

The purpose of this study was to determine the short-term and midterm outcomes of catheter-directed intervention (CDI) compared with anticoagulation (AC) alone in patients with submassive pulmonary embolism (sPE). This was a retrospective review of all patients treated for sPE between January 2009 and October 2014. Two groups were identified on the basis of the therapy: AC and CDI. End points included complications, mortality, and change in echocardiographic parameters. Standard statistical techniques were used. There were 64 patients who received AC and 64 patients who received CDI (five were initially treated with AC but did not improve or worsened; six received ≤8mg of tissue plasminogen activator). Most baseline characteristics, including the Pulmonary Embolism Severity Index, were similar among the AC and CDI groups. There was no difference in PE-related death (one in each group) or major bleeding events (three in the AC group, four in the CDI group), but CDIs had two additional procedural complications that required open heart surgery. CDIs showed significantly more minor bleeding events (6 vs 0; P= .028) and significantly shorter intensive care unit stay (2.7± 2.1 vs 5.6± 7.5days; P= .04). The mean difference in right ventricular/left ventricular ratio from baseline to the first subsequent echocardiogram (within 30days) showed a trend for higher reduction in favor of CDI (AC, 0.17± 0.12; CDI, 0.27± 0.15; P= .076). Between 3 and 8months, significant improvement was evident within groups in all assessed right-sided heart echocardiographic parameters, but there was no difference between groups. Pulmonary hypertension (pulmonary artery pressure >40mm Hg) was present in 7 of 15 of the AC group vs 6 of 19 of the CDI group (P= .484). During the follow-up, dyspnea or oxygen dependence, not existing before the index PE event, was recorded in 5 of 49 (10.2%) of the AC patients and 8 of 52 (15.4%) of the CDI patients (P= .556). CDI for sPE can result in faster restoration of right ventricular function and shorter intensive care unit stay, but at the cost of a higher complication rate, with similar midterm outcomes compared with AC alone. A potential effect of CDI on mortality and pulmonary hypertension needs further investigation through larger studies.

Systemic Thrombolysis Increases Hemorrhagic Stroke Risk Without Survival Benefit Compared to Catheter-Directed Intervention for the Treatment of Acute Pulmonary Embolism

Systemic Thrombolysis Increases Hemorrhagic Stroke Risk Without Survival Benefit Compared to Catheter-Directed Intervention for the Treatment of Acute Pulmonary Embolism

The ABC of a Simple Method for Pulmonary Vein Angiography

Catheter-directed intervention to treat atrial fibrillation (AF) is becoming widely accepted procedure in current clinical practice. For assessment of pulmonary vein (PV) anatomy, angiography of left atrium (LA) and/or PV is often performed. We present a new, simple angiographic method for PVs and LA opacification using SL1 sheath. Total of 100 patients in our clinic underwent this procedure. In all of the cases good angiographic results were achieved. No immediate or late complications related to this procedure were observed.

Catheter-directed intervention and thrombolysis for the treatment of massive pulmonary embolism that caused cardiac arrest

Catheter-directed intervention and thrombolysis for the treatment of massive pulmonary embolism that caused cardiac arrest

Detection of Active Gastrointestinal Hemorrhage with CT Angiography: A 4½-year Retrospective Review

To retrospectively evaluate the performance of computed tomography (CT) angiography in the detection and localization of clinically active gastrointestinal (GI) hemorrhage of an unknown source.Eighty-six CT angiograms were obtained in 74 patients with the clinical diagnosis of acute GI hemorrhage of an unknown source. Results of CT angiography were recorded, and the patients' electronic medical records were reviewed for documentation of subsequent interventional procedures performed within 24 hours of the reference CT angiogram to diagnose or control ongoing GI hemorrhage. Surgical, endoscopic, and final pathologic reports, if available, were reviewed.Twenty-two of the 86 CT angiograms (26%) were positive for active hemorrhage, with findings confirmed in 19 of the 22 cases (86%). Thirteen cases were confirmed with angiography, five cases were confirmed with surgery, and one case was confirmed with autopsy. Sixty-four of the 86 CT angiograms were negative, and 59 (92%) of the CT angiograms required no further intervention. These patients were discharged without incident. There were no cases in which CT angiography was negative and subsequent angiography within 24 hours was positive. The overall sensitivity, specificity, accuracy, and positive and negative predictive value of CT angiography in the detection of active GI hemorrhage within this study population were 79%, 95%, 91%, 86%, and 92%, respectively.CT angiography provides valuable information that can be used to determine the appropriateness of catheter angiography and guide mesenteric catheterization if a bleeding source is localized. The authors' experience with this study cohort supports its use before angiography in those patients with acute GI bleeding of an unknown source who are being considered for catheter-directed intervention.

Catheter-Directed Embolectomy, Fragmentation, and Thrombolysis for the Treatment of Massive Pulmonary Embolism After Failure of Systemic Thrombolysis

The standard medical management for patients in extremis from massive pulmonary embolism (PE) is systemic thrombolysis, but the utility of this treatment relative to catheter-directed intervention (CDI) is unknown. We evaluated the effectiveness of CDI as part of a treatment algorithm for life-threatening PE. A retrospective review was performed on 70 consecutive patients with suspected acute PE over a 10-year period (from 1997 to 2006) who had been referred for pulmonary angiography and/or intervention. The criteria for study inclusion were patients who received CDI due to angiographically confirmed massive PE and hemodynamic shock (shock index, > or = 0.9). CDI involved suction embolectomy and fragmentation with or without catheter thrombolysis. Twelve patients were treated with CDI. There were seven men and five women (mean age, 56 years; age range, 21 to 80 years). Seven patients (58%) were referred for CDI after failing systemic infusion with 100 mg of tissue plasminogen activator, and five patients (42%) had contraindications to systemic thrombolysis. Catheter-directed fragmentation and embolectomy were performed in all patients (100%). Additionally, catheter-guided thrombolysis was performed in eight patients (67%). Technical success was achieved in 12 of 12 cases (100%). There were no major procedural complications (0%). Significant hemodynamic improvement (shock index, < 0.9) was observed in 10 of 12 cases (83%). The remaining two patients (17%) died secondary to cardiac arrest within 24 h. Ten of 12 patients (83%) survived and remained stable until hospital discharge (mean duration, 20 days; range, 3 to 51 days). In the setting of hemodynamic shock from massive PE, CDI is potentially a life-saving treatment for patients who have not responded to or cannot tolerate systemic thrombolysis.

CATHETER-DIRECTED EMBOLECTOMY, FRAGMENTATION, AND THROMBOLYSIS FOR THE TREATMENT OF MASSIVE PULMONARY EMBOLISM AFTER FAILURE OF SYSTEMIC THROMBOLYSIS

PURPOSE: The standard medical management for patients in extremis from massive pulmonary embolism (PE) is systemic thrombolysis, but the utility of this treatment relative to catheter-directed intervention (CDI) is unknown. We evaluated the effectiveness of CDI (embolectomy, fragmentation, ± thrombolysis) used as part of a treatment algorithm for life-threatening pulmonary embolism.

The Small Left Ventricle: How Small is Too Small for Biventricular Repair?

Left ventricular hypoplasia is associated with a variety of congenital heart defects, including critical aortic stenosis, unbalanced atrioventricular canal, and total anomalous pulmonary venous connection, and is almost uniformly fatal without surgical or catheter-directed intervention. Accurately determining whether the left ventricle can adequately support the systemic circulation can be challenging and may be approached in a variety of ways, depending on the cardiac defect. The decision is more difficult in the present era of pediatric cardiology and cardiothoracic surgery because other options, such as the Norwood procedure and cardiac transplantation, are available to infants with left ventricular hypoplasia with improving survival. This report is a review of the present understanding of left ventricular hypoplasia and gives suggestions about how to stratify these complex patients to single versus two-ventricle repair. Copyright 1999 by W.B. Saunders Company

Results of 100 cases of pulse-spray thrombolysis for acute and subacute leg ischaemia

Pulse-spray thrombolysis is a rapid technique for the treatment of limb ischaemia of recent onset. Early results have been published but the longer term results are not known. This study consisted of a series of 100 legs with acute and subacute ischaemia treated using this method with a follow-up interval of up to 3 years. Eighty-three limbs were classified as Fontaine grade III or IV and 42 had a sensory or motor deficit. Sixty-seven limbs were treated with pulse spray alone and 33 had an additional low-dose infusion. In 71 cases an additional catheter-directed intervention was required. Median duration of lysis was 135 (range 35-1540) min and median dose of recombinant tissue plasminogen activator used was 18 (range 4-61) mg. Complete radiological patency was achieved in 79 limbs and the ankle:brachial pressure index improved from a median of 0 (range 0-0.8) to 0.8 (range 0-1.5) (P < 0.0001). At 30 days ten patients had died, eight needed amputation and a further 11 had rethrombosed. Cumulative limb salvage rate at 30 months was 79 per cent (standard error 8) and the estimated cumulative patency rate for successful cases was 72 per cent (standard error 10). The incidence of major bleeding was 7 per cent and of minor bleeding 24 per cent. There were no haemorrhagic strokes but three thrombotic strokes occurred within 30 days of thrombolysis. Pulse-spray thrombolysis achieves rapid and safe revascularization of acute and subacute leg ischaemia.