Catheter-directed Thrombolysis For Pulmonary Embolism Research Articles

F-22 | Clinical Outcomes for Patients with Thrombocytopenia who underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: An Analysis of the National Inpatient Sample

F-22 | Clinical Outcomes for Patients with Thrombocytopenia who underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: An Analysis of the National Inpatient Sample

F-26 | Clinical Outcomes for Patients with Obesity who underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: An Analysis of the National Inpatient Sample

F-26 | Clinical Outcomes for Patients with Obesity who underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: An Analysis of the National Inpatient Sample

F-27 | Clinical Outcomes for Patients with Peripheral Arterial Disease who underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: An Analysis of the National Inpatient Sample

F-27 | Clinical Outcomes for Patients with Peripheral Arterial Disease who underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: An Analysis of the National Inpatient Sample

F-21 | Clinical Outcomes for Catheter-Directed Thrombolysis for Pulmonary Embolism in Octogenarians, Nonagenarians, and Centenarians: A retrospective cohort study

F-21 | Clinical Outcomes for Catheter-Directed Thrombolysis for Pulmonary Embolism in Octogenarians, Nonagenarians, and Centenarians: A retrospective cohort study

OR11-2 | Sex Differences in Outcomes Among Patients who Underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: A Retrospective Cohort Study

OR11-2 | Sex Differences in Outcomes Among Patients who Underwent Catheter-Directed Thrombolysis for Pulmonary Embolism: A Retrospective Cohort Study

Effectiveness and safety of catheter-directed thrombolysis for pulmonary embolism in key patient subgroups: results of an individual patient level analysis

Abstract Background The effectiveness of catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE) has been rarely investigated in subgroups of patients at a higher risk of complications. Furthermore, this group of patients has been excluded from prior and ongoing phase 3 trials with CDT. Purpose To assess the efficacy and safety of catheter-directed thrombolysis for pulmonary embolism among specific patient subpopulations. Material and methods We conducted an individual patient-level analysis of patient data from 16 cohort studies and randomized trials of CDT for intermediate- and high-risk acute PE. Studies were identified on the basis of a systematic review of the literature. We focused on early clinical outcomes, including haemodynamic decompensation, intracranial bleeding, major bleeding, and death, as well as on the changes in the mean pulmonary artery pressure (mPAP) before and after CDT. We predefined three subgroups of at-risk patients: (i) older age (i.e. ≥75 years), (ii) active cancer, and (iii) surgery in the prior 4 weeks. Results We studied 1244 patients, of whom 586 (47.1%) were women. The median age was 61 (Q1-Q3; 50-71) years. There were 202 (16.3% of total available) patients aged 75 years or older, 101 (10%) with active cancer, and 108 (14.8%) with prior surgery. A total of 946 (89.3%) patients had intermediate-risk PE, and 113 (10.7%) were classified in the high-risk group. Patients aged ≥75 years more frequently suffered haemodynamic decompensation (7.5% vs 1.6% aged <75 years; p< 0.001), major bleeding (12.7% vs 4.5%; p<0.001), and death (9.2% vs 2.2%; p<0.001); Table 1. In a multivariable logistic regression model, age remained associated with death, major bleeding, and haemodynamic decompensation after adjustment for a key prognostic factor (high-risk PE). The same, except for decompensation, was observed after conditioning for sex, high-risk PE, and cancer status. Patients with active cancer showed a tendency to a higher 30-day case fatality when compared with patients with no active cancer, without reaching statistical significance; Table 1. Recent surgery did not appear to influence the outcome rate in this cohort. No differences were found among the three subgroups regarding the reduction of the mPAP following CDT ; Table 2. Conclusions Our results point to age as a strong predictor of early mortality and decompensation in patients undergoing CDT, even after adjusting for the higher rate of high-risk PE in the elderly. The clinical net benefit of CDT in the elderly when accounting for bleeding and the risk of haemodynamic decompensation remains unclear.Efficacy and safety outcomes of CDTmPAP values before and after CDT

Utilization trends and outcomes of catheter-directed thrombolysis for pulmonary embolism in the US by race/ethnicity.

Contemporary data on catheter-directed thrombolysis (CDT) utilization trends and associated hospital outcomes in pulmonary embolism (PE) n the US is limited. Using the nationwide inpatient sample database, we identified patients hospitalized for acute PE treated with CDT from January 1, 2008, to December 31, 2018. Cochrane-Armitage test was used to evaluate the temporal trends in utilization, hospital mortality, and major bleeding rates. Multivariate logistic regression was used to compare differences in the outcomes across race/ethnicity, 4444 patients (unweighted hospitalizations) underwent CDT during the study period. The mean age ± standard deviation of the population was 58 ± 16years and the majority were males (54%). 3269 (73.6%) patients were non-Hispanic White (NHW), 802 (18.0%) patients were non-Hispanic Black (NHB), and 373 (8.4%) patients were of 'other' races/ethnicities. There was a more than tenfold increase in CDT use in 2018 compared to 2008. The total mortality and bleeding rates were approximately 7 and 10% respectively. Hospital mortality rates trended down across all races/ethnicities during the study period. A similar downward trend in bleeding rates was noted in NHB only (28.6% vs 10.7%, p = 0.04). In-hospital mortality and major bleeding odds were comparable across all races/ethnicities were comparable. NHB patients and other races were more likely to require blood transfusion and incur higher hospitalization costs compared with NHW patients. CDT use increased significantly in the US during the study period with a corresponding downward trend in in-hospital mortality across all races, and bleeding rates in NHB.

Abstract No. 281 Catheter-directed thrombolysis for pulmonary embolism: an analysis of the National Inpatient Sample

Abstract No. 281 Catheter-directed thrombolysis for pulmonary embolism: an analysis of the National Inpatient Sample

Clinical outcomes of very elderly patients treated with ultrasound-assisted catheter-directed thrombolysis for pulmonary embolism: a systematic review.

Pulmonary embolism (PE) is a significant cause of death in the very elderly (≥ 75years) population. Ultrasound-assisted catheter-directed thrombolysis (USCDT) emerges to improve thrombolysis safety and efficacy. However, outcomes in very elderly patients are unknown, as randomized controlled trials exclude this population. Recently, we demonstrated acute kidney injury (AKI) and ischemic hepatitis in an octogenarian intermediate-risk PE patient treated with USCDT. Considering the lack of evidence, we undertook a systematic review to evaluate the clinical outcomes in very elderly PE patients treated with USCDT. We searched for very elderly PE patients treated with USCDT from 2008 to 2019. Additionally, we conducted another systematic review without age restriction to update previous evidence and compare both populations. We also did an exploratory analysis to determine if thrombolysis was followed based on current guidelines or impending clinical deterioration factors. We identified 18 very elderly patients (age 79.2, 75-86), mostly female and with intermediate-risk PE. We found an intracranial hemorrhage (ICH), and a right pulmonary artery rupture. Additionally, two significant bleedings complicated with transient AKI, and one case of AKI and ischemic hepatic injury. The patients who survived all had clinical and echocardiographic in-hospital improvement. Despite low rt-PA doses, ICH and major bleeding remain as feared complications. Thrombolysis decision was driven by impending clinical deterioration factors instead of international guideline recommendations. Our data do not suggest prohibitive risk associated with USCDT in very elderly intermediate and high-risk PE patients. Despite long-term infusions and right ventricular dysfunction, AKI and ischemic hepatic injury were infrequent.

Fibrinogen Monitoring during Catheter-Directed Thrombolysis for Pulmonary Embolism: Can It Be Cleaved from Our Practice?

Fibrinogen Monitoring during Catheter-Directed Thrombolysis for Pulmonary Embolism: Can It Be Cleaved from Our Practice?

Safety of Therapeutic Anticoagulation with Low-Molecular-Weight Heparin or Unfractionated Heparin Infusion during Catheter-Directed Thrombolysis for Acute Pulmonary Embolism

PurposeTo examine the safety of therapeutic-dose anticoagulation during catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE). Materials and MethodsA retrospective review of 156 consecutive cases (age, 56.6 ± 15.4 years; 85 males) of CDT with alteplase for acute PE (symptoms, <14 days) between 2009 and 2019 was performed. All patients received full-dose anticoagulation before, during, and after thrombolysis with low-molecular-weight heparin (LMWH) (n = 45) or unfractionated heparin (n = 111) infusion. Massive PE was diagnosed in 21 of 156 patients at presentation; submassive PE was diagnosed in 135 of 156 patients at presentation. The Simplified Pulmonary Embolism Severity Index was ≥1 in 69 of 156 patients. ResultsThere were 4 mild (2.6%), 3 moderate (1.9%), and 3 severe (1.9%) hemorrhagic complications (Global Use of Strategies to Open Occluded Arteries), 1 of which (0.6%) was intracranial. No significant differences in hemorrhagic complication rates (P = .3, P = 1.0, and P = .6, respectively) or general complication rates (Society of Interventional Radiology [SIR] minor, P = .2; SIR major, P = .7) were noted between the LMWH and heparin groups. Mean pulmonary arterial pressure for the entire cohort improved from 28.9 ± 7.6 mmHg to 20.4 ± 6.5 mmHg (P < .001), whereas the Miller score improved from 19.3 ± 4.6 to 7.3 ± 3.9 (P < .001). The average infusion duration was 26 ± 11.9 hours over 2.3 ± 0.6 total visits to the angiography lab, during which a mean of 27.85 ± 14.2 mg of tissue plasminogen activator were infused. ConclusionsTherapeutic anticoagulation during CDT for PE appears to be safe. The current study did not find a significant difference between LMWH and heparin infusion with respect to hemorrhagic and general complication rates.

Urban-Rural Variation in Use of Thrombolytic Therapy for Pulmonary Embolism

Background: Thrombolytic therapy is widely accepted for persistent hypotension or shock due to acute pulmonary embolism (PE), with randomized and observational studies demonstrating earlier hemodynamic improvement and possible mortality benefit. The extent to which thrombolytic therapy is used in urban versus non-urban settings is unclear. Methods: We conducted a retrospective cohort study of 92,706 (unweighted) and 180,189 (weighted) admissions with primary diagnosis of PE, for patient aged 18 years and above, that occurred in 2016, at all general acute-care hospitals within the 27 states included in the Nationwide Readmissions Database (NRD). Admissions for primary PE diagnosis and their respective severity levels (minor, moderate, major, extreme) were identified using the All Patient Refined Diagnosis Related Groups. We identified systemic and catheter-directed thrombolytic use using ICD-10-PCS codes. Hospital locations were classified as metropolitan (population ≥50K), micropolitan (10K-50K), and noncore (&amp;lt;10K). National estimates were calculated using post-stratification weights designed to compensate for any over- or under-represented hospital types in the NRD relative target universe of all hospitals in the U.S. PROC SURVEYFREQ and SURVEYLOGISTICS (SAS 9.4) were used to account for complex sampling design in variance calculations. Results: Of all primary PE admissions, 89.5% (95% CI, 88.7-90.2%) occurred at hospitals in metropolitan, 8.0% (95% CI, 7.3-8.7%) in micropolitan, and 2.6% (95% CI, 2.3-2.8%) in noncore areas. Rates of systemic thrombolytic use differed by location: 2.5% (95% CI, 2.3-2.6%) of admissions in metropolitan, 1.1% (95% CI, 0.7-1.4%) in micropolitan, and 0.1% (95% CI, 0-0.3%) in noncore areas (P&amp;lt;.001 for block test; Figure 1). Rates of catheter-directed thrombolytic use also differed: 2.4% (95% CI, 2.1-2.8%) of admissions in metropolitan, 1.5% (95% CI, 0.5-2.5%) in micropolitan, and 0.1% (95% CI, 0-0.2%) in noncore areas (P&amp;lt;.001 for block test). Differences persisted after adjusting for severity of illness for both approaches of thrombolysis (P&amp;lt;.001 in each block test of hospital location). Of patients with highest severity (major and extreme), systemic thrombolysis occurred in 4.0% (95% CI, 3.7-4.3%) of admissions in metropolitan, 1.9% (95% CI, 1.2-2.6%) in micropolitan, and 0.5% (95% CI, 0-1.1%) in noncore hospitals. In this same population, catheter-directed thrombolysis occurred in 2.4% (95% CI, 2.1-2.8%) of admissions in metropolitan, 1.5% (95% CI 0.5-2.5%) in micropolitan, and 0.1% (95% CI, 0-0.2%) in noncore hospitals. Conclusion: There was significant variation in use of systemic and catheter-directed thrombolysis for pulmonary embolism by hospital location. Thrombolytic therapy was rarely reported among noncore hospitals and occurred at a substantially lower rate at micropolitan than at metropolitan hospitals even when adjusted for illness severity. Implications: Efforts should be directed to understand drivers of urban-rural differences in use of thrombolytic therapies (e.g., knowledge, experience, support, resources) to identify potential levers to increase appropriate use of thrombolytic therapy particularly at hospitals in smaller, non-metropolitan communities. Disclosures Rosovsky: Janssen Pharmaceuticals: Consultancy, Research Funding; Bristol-Myers Squibb: Research Funding; Dova Pharmaceuticals: Consultancy.

Catheter-Directed Thrombolysis for Pulmonary Embolism: The State of Practice

Acute pulmonary embolism (PE) is a major public health problem. It is the third most common cause of death in hospitalized patients. In the United States, there are up to 600,000 cases diagnosed per year with 100,000-180,000 acute PE-related deaths. Common risk factors include underlying genetic conditions, acquired conditions, and acquired hypercoagulable states. Acute PE increases the pulmonary vascular resistance and the load on the right ventricle (RV). Increased RV loading causes compensatory RV dilation, impaired contractility, tachycardia, and sympathetic activation. RV dilation and increased intramural pressure decrease diastolic coronary blood flow, leading to RV ischemia and myocardial necrosis. Ultimately, insufficient cardiac output from the RV causes left ventricular under-filling which results in systemic hypotension and cardiovascular collapse. Current prognostic stratification strategy separates acute PE into massive, submassive, and low-risk by presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive, and low-risk acute PE have mortality rates of 25%-65%, 3%, and <1%, respectively. Current PE management includes the use of anticoagulation alone, systemic thrombolysis, catheter-directed thrombolysis, and surgical embolectomy. This article will describe the current state of practice for catheter-directed thrombolysis and its role in the management of acute PE.

4:03 PM Abstract No. 228 Ultrasound-assisted catheter-directed thrombolysis for submassive pulmonary embolism: efficacy in relief of right heart strain

To determine the outcomes, safety profile, and efficacy of ultrasound-assisted catheter-directed thrombolysis for pulmonary embolism with right heart strain. The charts of 30 consecutive patients who underwent CDT as treatment for pulmonary embolism were reviewed. Risk factors for bleeding were noted. Indicators of right heart strain on computed tomography and echocardiogram, as well as degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. Right ventricular systolic pressure decreased from an average of 53.1 mm Hg to 38.5 mm Hg (p = <0.001) and average Qanadli index of pulmonary vascular obstruction decreased from 49 to 34 (p = <0.001) after CDT. The average ratio of RV/LV diameter decreased from 1.48 to 1.17 (p = <0.001) The number of patients with RV hypokinesis decreased significantly (p = 0.016) from 19 (95% of those with available data) to 12 (60%). The number of patients with RV dilation decreased significantly (p = 0.031) from 19 (95% of those with available data) to 13 (65%). Nine (30%) patients had three or more minor contraindications to thrombolysis and fourteen (47%) had had major surgery in the month prior to CDT. No patients experienced major or moderate bleeding attributed to CDT. In our experience CDT proved effective in the rapid alleviation of right heart strain with minimal bleeding risk. Right heart strain is associated with increased mortality and long-term morbidity in pulmonary embolism and CDT may allow for a safe means of improving outcomes in submassive pulmonary embolism. We found CDT to be a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery.Tabled 1Measures of Right Heart Strain Before and After CDTPre-CDT MeanSDPost-CDT MeanSDDifference MeanSDP ValueRVSP53.115.138.510.214.512.6<0.001RV/LV1.480.321.170.260.322.16<0.001Qanadli Index4918341315.410.1<0.001 Open table in a new tab

Fibrinolytic and Anticoagulation Therapy in Patients Undergoing Ultrasound-Assisted Catheter-Directed Thrombolysis for Pulmonary Embolism.

Ultrasound-assisted, catheter-directed thrombolysis (UA-CDT) relieves right ventricular stress without a significant increase in the risk of bleeding compared to systemic thrombolysis. Although concomitant anticoagulation is provided to prevent thrombus expansion, the optimal anticoagulation regimen in patients receiving UA-CDT remains unknown. We sought to describe anticoagulation practices for patients receiving UA-CDT. Patients receiving UA-CDT for acute pulmonary embolism (PE) between Jan 1, 2013 to Sept 30, 2014 at a single center were analyzed. We collected patient characteristics, fibrinolytic and anticoagulant usage as well as clinical outcomes. Fourteen patients were included in the final analysis. The mean alteplase dose was 16.8 ± 5.6 mg and 24.3 ± 3.4 mg in unilateral and bilateral PE, respectively. Mean unfractionated heparin (UFH) rates were 7.4 (±2.17) IU/kg/hr and 12.4 (±3.1) IU/kg/hr during and after fibrinolytic therapy, respectively. The median aPTT was 42.4 sec [IQR 34.5-51.8] and 77.9 sec [IQR 66.5-96.8] during and after fibrinolytic therapy, respectively. There were no recurrent VTE within 30 days of hospital discharge. One patient had a major bleeding event (intracranial hemorrhage). In patients with acute PE, our institution utilized low levels of anticoagulation during fibrinolytic administration and therapeutic doses after completion of fibrinolytic infusion. Standardized protocols for anticoagulation during UA-CDT are warranted.

TCT-90 HAS-BLED Score and Other Predictors of Bleeding in Catheter-Directed Thrombolysis for Pulmonary Embolism

Catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE) aims to reduce bleeding complications while maintaining efficacy compared to systemic fibrinolysis. While studies have shown CDT to have superior hemodynamic outcomes compared to systemic anticoagulation alone,

Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE). The use of CDT for the treatment of acute submassive and massive PE is increasing in frequency. However, its safety and efficacy have not been well elucidated. This study is made of two parts: one is a two-center registry of acute PE patients treated with CDT. The safety outcome evaluated was any major complication including fatal, intracranial (ICH), intraocular, or retroperitoneal hemorrhage or any overt bleeding requiring transfusion or surgical repair. The efficacy outcome was acute change in invasive pulmonary artery systolic pressure (PASP). The second part is a meta-analysis of all contemporary studies that used CDT for PE. Reported outcomes are the same as in the registry, with the addition of right ventricular to left ventricular (RV/LV) ratio change. In the registry, 137 patients were included (age 59 ± 15, 50% male, 88% submassive PE). ICH occurred in two patients and major complications in 13 (9.4%). PASP decreased post procedure by 19 ± 15 mm Hg (95% CI 16-23). In the meta-analysis, 16 studies were included with 860 patients. Rate of ICH was 0.35% and the major complication rate was 4.65%, most requiring transfusion only. In-hospital mortality was 12.9% in the massive and 0.74% in the submassive group. All studies showed improvement in PASP and/or RV/LV ratio post CDT. CDT is associated with a low major complication rate. Randomized studies are needed to evaluate its efficacy relative to anticoagulation alone. © 2017 Wiley Periodicals, Inc.