Treatment Of Embolism Research Articles

Patient Outcomes of Definitive Diverticular Hemorrhage After Colonoscopic, Medical, Surgical, or Embolization Treatment.

There are few reports of clinical outcomes or the natural history of definitive diverticular hemorrhage (DDH). To describe 1-year clinical outcomes of patients with documented DDH treated with colonoscopic hemostasis, angioembolization, surgery, or medical treatment. DDH was diagnosed when active bleeding or other stigmata of hemorrhage were found in a colonic diverticulum during urgent colonoscopy or extravasation on angiography or red blood cell (RBC) scanning. This was a retrospective analysis of prospectively collected data of DDH patients from two referral centers between 1993 and 2022. Outcomes were compared for the four treatment groups. The Kaplan-Meier analysis was for time-to-first diverticular rebleed. 162 patients with DDH were stratified based on their final treatment before discharge-104 colonoscopic hemostasis, 24 medical treatment alone, 19 colon surgery, and 15 angioembolization. There were no differences in baseline characteristics, except for a higher Glasgow-Blatchford score in the angioembolization group vs. the colonoscopic group. Post-treatment, the colonoscopic hemostasis group had the lowest rate of RBC transfusions and fewer hospital and ICU days compared to surgical and embolization groups. The medical group had significantly higher rates of rebleeding and reintervention. The surgical group had the highest postoperative complications. Medically treated DDH patients had significantly higher 1-year rebleed and reintervention rates than the three other treatments. Those with colonoscopic hemostasis had significantly better clinical outcomes during the index hospitalization. Surgery and embolization are recommended as salvage therapies in case of failure of colonoscopic and medical treatments.

New horizons in subdural haematoma.

Subdural haematoma (SDH) is a common injury sustained by older people living with frailty and multimorbidity, and typically following falls from a standing height. Anticoagulant and antiplatelet use are commonly indicated in older people with SDH, but few data inform decision-making surrounding these agents in the context of intracranial bleeding. Opposing risks of rebleeding and thrombosis must therefore be weighed judiciously. Decision-making can be complex and requires detailed awareness of the epidemiology to ensure the safest course of action is selected for each patient. Outcomes of surgical decompression in acute SDH are very poor in older people. However, burr hole drainage can be safe and effective in older adults with symptomatic chronic SDH (cSDH). Such patients need careful assessment to ensure symptoms arise from cSDH and not from coexisting medical pathology. Furthermore, the emerging treatment of middle meningeal artery embolisation offers a well-tolerated, minimally invasive intervention which may reduce the risks of rebleeding in older adults. Nonetheless, UK SDH management is heterogenous, and no accepted UK or European guidelines exist at present. Further randomised trial evidence is required to move away from clinical practice based on historic observational data.

Academician Viktor Sergeyevich Savelyev (1928–2013) (on the 95th anniversary of his birth)

Outstanding surgeon, scientist, teacher and organizer of healthcare, founder of a large surgical school, Hero of Socialist Labor (1988), academician of the USSR Academy of Medical Sciences (1974), RAMS (1991) and RAS (1997), laureate of the USSR State Prize (1975), the State Prize of the Russian Federation (1992), Demidov Prize (2002) and the A. N. Bakulev Prize (2002), Professor Viktor Sergeevich Savelyev was born on February 24, 1928 in the village of Pakhotny Ugol of the Bondarsky district of the Tambov region in the family of Sergei Dmitrievich Savelyev, a wood sawmill worker, and Olga Kuzminichna, a housewife. In 1945, Viktor Sergeevich entered the 2nd Moscow Medical Institute (now the Pirogov Russian National Research Medical University). After graduating in 1951, he studied in residency at the Department of Faculty Surgery, which was headed by the academician A. N. Bakulev, and was stayed at the department as an assistant. After defending his PhD thesis in 1955, he was appointed a teacher. In 1959, V. S. Savelyev successfully defended his doctoral dissertation, in 1961, he passed the academic title of Professor, in 1967, he was elected the head of the Department of Faculty Surgery. Viktor Sergeevich fully became the successor of A. N. Bakuleva and made the very great contribution to the development of domestic cardiac surgery. The works of V. S. Savelyev played a huge role in the formation and rapid development of vascular surgery. The clinic he headed has accumulated the world’s largest experience in the treatment of acute thrombosis and embolism of the main arteries. Viktor Sergeevich is rightfully one of the founders of modern Russian phlebology. He also made a significant contribution to the development of surgery of the stomach, intestines, bile ducts and pancreas. He was one of the first in the country to use organ-preserving operations on the stomach for complicated duodenal ulcer. Many of Viktor Sergeevich’s works were devoted to various aspects of postoperative management of patients, infusion therapy and parenteral nutrition, pathogenesis, diagnosis and treatment of sepsis. V. S. Savelyev and his students made a significant contribution to the development of abdominal endoscopy. V. S. Savelyev was a major organizer of domestic healthcare, for 34 years he held the post of the chief surgeon of the Ministry of Health of Russia. He was the Chairman of the Scientific Society of Surgeons of Russia (ROH), founder and president of the Russian Association of Phlebologists, editor-in-chief of journals «Thoracic and Cardiovascular Surgery» and «Phlebolymphology». Under his leadership and with his participation as the scientific consultant, 70 doctoral and 180 candidate dissertations were defended. He was the author and co-author of more than 500 scientific papers, including 24 monographs and manuals. The academician Viktor Sergeevich Savelyev died on December 25, 2013 and was buried in Moscow at the Troyekurovo Cemetery.

Successful Treatment of Massive Pulmonary Embolism with Rescue Fibrinolysis in Young Patient with Homocystinemia - Case Report

Abstract Pulmonary embolism (PE) is the most frequently missed diagnosis in the urgent clinical department with serious consequences. Patients with unprovoked PE have increased risk of recurrent PE. Approximately 5 to 8% of PE patients have inherited thrombophilias. A solated homocystinemia is a rare cause of unprovoked acute pulmonary embolism. Timely diagnosis and proper treatment can prevent complications, costs and mortality and provide patient better quality of life. We are presenting a 42-year-old woman was admitted to our emergency department with the first episode of severe dyspnea and chest pain. She had no history of previous cardiovascular or respiratory disease and no history of previous pulmonary embolism (PE) or deep vein thrombosis (DVT). Urgent echocardiography showed indirect signs of pulmonary embolism which was confirmed by the pulmonary artery CT angiography performed one day after the patient’s admission. After two days of heparin infusion, she developed a hemodynamic instability with cardiogenic shock and was treated successfully with fibrinolysis. After the clinical stabilization, she was put on the rivaroxaban therapy, which was recommended for additional six months. The thrombophilia profile was done two weeks after stopping the therapy with rivaroxaban. The thrombophilia panel came back positive for high levels of homocysteine (67 μmol/L), with other thrombophilia results within normal limits. The patient was stable during the follow-up period. Pulmonary embolism should be always suspected in younger patients with acute severe dyspnea even without provocable risk factors. High suspicion level and fast diagnosis are lifesaving. In younger patients presented with unprovoked pulmonary embolism, clinicians should consider inherited prothrombotic factors and homocystinemia as a potential cause. Rescue fibrinolysis is a lifesaving therapy in hemodynamic worsening in intermediate high-risk PE patients. A longer anticoagulation therapy should be considered in these cases with novel oral anticoagulants that are recommended as safer and superior therapy.

Single Component Polymers, Polymer Blends, and Polymer Composites for Interventional Endovascular Embolization of Intracranial Aneurysms.

Intracranial aneurysm is the abnormal focal dilation in brain arteries. When untreated, it can enlarge to rupture points and account for subarachnoid hemorrhage cases. Intracranial aneurysms can be treated by blocking the flow of blood to the aneurysm sac with clipping of the aneurysm neck or endovascular embolization with embolics to promote the formation of the thrombus. Coils or an embolic device are inserted endovascularly into the aneurysm via a micro-catheter to fill the aneurysm. Many embolization materials have been developed. An embolization coil made of soft and thin platinum wire called the "Guglielmi detachable coil" (GDC) enables safer treatment for brain aneurysms. However, patients may experience aneurysm recurrence because of incomplete coil filling or compaction over time. Unsatisfactory recanalization rates and incomplete occlusion are the drawbacks of endovascular embolization. So, the fabrication of new medical devices with less invasive surgical techniques is mandatory to enhance the long-term therapeutic performance of existing endovascular procedures. For this aim, the current article reviews polymeric materials including blends and composites employed for embolization of intracranial aneurysms. Polymeric materials used in embolic agents, their advantages and challenges, results of the strategies used to overcome treatment, and results of clinical experiences are summarized and discussed.

Accuracy of the Diagnosis of Subsegmental Pulmonary Embolism Among General Radiologists

Background: Diagnosis and treatment of subsegmental pulmonary embolism (SSPE) are challenging. Contrary to segmental PE, little is known about the accuracy of the diagnosis of SSPE Methods A retrospective matched cohort study was conducted at a university-affiliated community hospital. Computed tomographic angiography (CTAs) were reviewed from August 2018 to December 2021. Patients who were 18-year-old or older with the diagnosis of SSPE were included. Patients with a concurrent segmental PE or deep venous thrombosis (DVT) were excluded. Another radiologist reviewed each CTA. Results Total of 43 patients with SSPE without segmental PE were identified. The mean age of subjects was 67 years. 24 (56%) patients were males, and 41 (95%) were white. 42 (97%) of CTAs were performed for suspected PE. One case was found incidentally. Forty patients (93%) received therapeutic anticoagulation. Three patients (7%) were discharged from the Emergency Department (ED) without therapeutic anticoagulation. The average duration of anticoagulation therapy was four-months. Another radiologist's review of the CTA on admission revealed a discordant diagnosis: 13 out of 43 (30%) cases were reported negative for SSPE. One case was reported for segmental PE Conclusion The accuracy of the diagnosis of SSPE is low as the discordance rate by different radiologists is high.More studies are needed to establish the diagnosis and guide treatment of SSPE.

Novel Deep Learning Denoising Enhances Image Quality and Lowers Radiation Exposure in Interventional Bronchial Artery Embolization Cone Beam CT

In interventional bronchial artery embolization (BAE), periprocedural cone beam CT (CBCT) improves guiding and localization. However, a trade-off exists between 6-second runs (high radiation dose and motion artifacts, but low noise) and 3-second runs (vice versa). This study aimed to determine the efficacy of an advanced deep learning denoising (DLD) technique in mitigating the trade-offs related to radiation dose and image quality during interventional BAE CBCT. This study included BMI-matched patients undergoing 6-second and 3-second BAE CBCT scans. The dose-area product values (DAP) were obtained. All datasets were reconstructed using standard weighted filtered back projection (OR) and a novel DLD software. Objective image metrics were derived from place-consistent regions of interest, including CT numbers of the Aorta and lung, noise, and contrast-to-noise ratio. Three blinded radiologists performed subjective assessments regarding image quality, sharpness, contrast, and motion artifacts on all dataset combinations in a forced-choice setup (-1=inferior, 0=equal; 1=superior). The points were averaged per item for a total score. Statistical analysis ensued using a properly corrected mixed-effects model with post hoc pairwise comparisons. Sixty patients were assessed in 30 matched pairs (age 64±15 years; 10 female). The mean DAP for the 6s and 3s runs was 2199±185 µGym² and 1227±90 µGym², respectively. Neither low-dose imaging nor the reconstruction method introduced a significant HU shift (p≥0.127). The 3s-DLD presented the least noise and superior contrast-to-noise ratio (CNR) (p<0.001). While subjective evaluation revealed no noticeable distinction between 6s-DLD and 3s-DLD in terms of quality (p≥0.996), both outperformed the OR variants (p<0.001). The 3s datasets exhibited fewer motion artifacts than the 6s datasets (p<0.001). DLD effectively mitigates the trade-off between radiation dose, image noise, and motion artifact burden in regular reconstructed BAE CBCT by enabling diagnostic scans with low radiation exposure and inherently low motion artifact burden at short examination times.

Anti-factor Xa as the preferred assay to monitor heparin for the treatment of pulmonary embolism.

The mainstay of acute pulmonary embolism (PE) treatment is anticoagulation. Timely anticoagulation correlates with decreased PE-associated mortality, but the ability to achieve a therapeutic activated partial thromboplastin time (aPTT) with unfractionated heparin (UFH) remains limited. Although some institutions have switched to a more accurate and reproducible test to assess for heparin's effectiveness, the anti-factor Xa (antiXa) assay, data correlating a timely therapeutic antiXa to PE-associated clinical outcomes remains scarce. We evaluated time to a therapeutic antiXa using intravenous heparin after PE response team (PERT) activation and assessed clinical outcomes including bleeding and recurrent thromboembolic events. This was a retrospective cohort study at NYU Langone Health. All adult patients ≥18 years with a confirmed PE started on IV UFH with >2 antiXa levels were included. Patients were excluded if they received thrombolysis or alternative anticoagulation. The primary endpoint was the time to a therapeutic antiXa level of 0.3-0.7 units/mL. Secondary outcomes included recurrent thromboembolism, bleeding and PE-associated mortality within 3 months. A total of 330 patients with a PERT consult were identified with 192 patients included. The majority of PEs were classified as sub massive (64.6%) with 87% of patients receiving a bolus of 80 units/kg of UFH prior to starting an infusion at 18 units/kg/hour. The median time to the first therapeutic antiXa was 9.13 hours with 93% of the cohort sustaining therapeutic anticoagulation at 48 hours. Recurrent thromboembolism, bleeding and mortality occurred in 1%, 5% and 6.2%, respectively. Upon univariate analysis, a first antiXa <0.3 units/ml was associated with an increased risk of mortality [27.78% (5/18) vs 8.05% (14/174), p = 0.021]. We observed a low incidence of recurrent thromboembolism or PE-associated mortality utilizing an antiXa titrated UFH protocol. The use of an antiXa based heparin assay to guide heparin dosing and monitoring allows for timely and sustained therapeutic anticoagulation for treatment of PE.

Non-surgical management of chronic subdural hematoma: insights and future perspectives from an international survey including neurosurgeons from 90 countries worldwide

Background Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions. Although surgical evacuation is still the gold standard for treatment, recent advances have led to the development of other management strategies, such as medical therapies and endovascular middle meningeal artery (MMA) embolization. Through this international survey, we investigated the global trends in cSDH management, focusing on medical and endovascular treatments. Design and participants A 14-question, web-based, anonymous survey was distributed to neurosurgeons worldwide. Results Most responders do not perform MMA embolization (69.5%) unless for specific indications (29.6%). These indications include residual cSDH after surgical evacuation (58.9%) or cSDH in patients on antiplatelet medications to avoid surgical evacuation (44.8%). Survey participants from teaching versus non-teaching hospitals (p = 0.002), public versus private hospitals (p = 0.022), and Europe versus other continents (p < 0.001) are the most users of MMA embolization. A large number of participants (51%) declare they use a conservative/medical approach, mainly to avoid surgery in patients with small cSDH (74.8%). Conclusions This survey highlights the current trends of cSDH management, focusing on conservative and MMA embolization treatment strategies. Most responders prefer a conservative approach for patients with small cSDHs not requiring surgical evacuation. However, in higher-risk scenarios such as residual hematomas after surgery or patients on antiplatelet medications, MMA embolization is regarded as a reasonable option by participants. Future studies should clarify the indications of MMA embolization, including appropriate patient selection and efficacy as a stand-alone procedure.

Isolated bronchial hemangioma causing recurrent hemoptysis: A case report.

The development of bronchial hemangioma in adults is rare, and massive hemoptysis due to diffuse vascular proliferation of bronchial hemangioma is fatal. A case of a 29-year-old woman kept massive hemoptysis even after being underwent repeated interventional embolization for recurrent massive hemoptysis. Eventually, the patient was performed the operation of right upper lung lobectomy and bronchial hemangioma with extracorporeal membrane oxygenation support and was followed up for 4 years without recurrent hemoptysis. Bronchial hemangioma. For patients with bronchial angiomas bonded with bronchial artery-pulmonary arteriovenous fistulae, the early surgical resection is recommended if bronchial artery embolization (BAE) is considered ineffective.

The value of endoscopically-placed metal clips for transcatheter arterial embolization in the treatment of recurrent acute non-variceal upper gastrointestinal bleeding

ObjectiveAcute nonvariceal upper gastrointestinal bleeding (ANVUGIB) is a common clinical emergency. Transcatheter arterial embolization (TAE) is usually used to locate the bleeding site and provide interventional embolization. During TAE, there is a low positive rate of angiography, and localization of the culprit vessel is difficult. The purpose of this study was to demonstrate the role of preplaced metal clips in TAE for ANVUGIB patients.Materials and methodsPatients with ANVUGIB in whom bleeding sites were identified endoscopically and treated with TAE from January 1st, 2005 to July 1st, 2021 were retrospectively included. According to the presence or absence of preplaced metal clips, they were divided into two groups. The main outcome measurements included the clinical success rate and rebleeding rate. Secondary outcome measurements included the mortality rate and the need for surgery. Predictors of the clinical success rate were assessed with univariate analysis and multivariate analysis.ResultsA total of 102 patients were included in this study, and all of them had undergone arterial embolization. There were 73 cases in the group with metal clips and 29 cases in the group without metal clips with consistent baseline information. The group with metal clips had a higher clinical success rate (82.2% vs. 45.0%, P < 0.001), lower rebleeding rate (8.2% vs 27.6%, P = 0.039) and additional surgery rate (11.0% vs 20.7%, P < 0.001) than the group without metal clips. In univariate analysis, ROCKALL score and preplaced metal clip marking were shown to affect clinical success rate. In multivariate analysis, metal clip marking was found to facilitate clinical success (OR = 3.750, 95CI = 1.456–9.659, P = 0.004).ConclusionIn ANVUGIB patients, preplaced metal clips could improve the clinical success rate of TAE and reduce the mortality rate and the risk of rebleeding.

Catheter-directed therapy for treatment of acute pulmonary embolism in a teenage patient: The role of close cooperation between the Pulmonary Embolism Response Team and pediatric physicians.

Catheter-directed therapy for treatment of acute pulmonary embolism in a teenage patient: The role of close cooperation between the Pulmonary Embolism Response Team and pediatric physicians.

Development and Validation of RP-HPLC Method for the Determination of Enoxaparin Sodium in Dry Injection Formulation.

Enoxaparin sodium is an anticoagulant medication that is used as a blood thinning agent. It is mostly used for the treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE). It is also used in certain surgeries and during pregnancy. For the treatment of acute coronary syndrome (ACS) and heart attacks, it may be used. Enoxaparin sodium was validated by the RP-HPLC method. A simple RP-HPLC method was developed in a single HPLC run in a dry powder injection formulation. All injections of HPLC sample were 20 μL volume. The chromatographic separation was completed in the isocratic mode. The used column was USP-L8 (250 mm × 4.6 mm) of BDS type of 10 μm meters in the same mobile phase throughout the analysis by using methanol and ultrapure water with a ratio of 7:93, respectively. The flow rate was 1.0 mL/min. The mobile phase was filtered through 0.45 μm filter paper, and isocratic elution was performed. The refractive index (RI) detector was used to analyze this sample. The specific peak of enoxaparin sodium was observed at 5:56 min. The calculated detection limit (LOD) was 0.351 ppm, and the calculated quantitation limit was 1.063 ppm. In repeatability of precision, the average calculated assay (%) was 100.85%, and the calculated RSD (%) was 0.01. In the accuracy test, the RSD (%) was 0.50, and the mean recovery (%) was 100.35. The system's suitability was within the limit. This newly developed method is proposed according to ICH guidelines, and rules and can be applied effectively for the exact estimation of enoxaparin sodium in injection formulation. This newly developed methodology is affordable in cost as long as less time is taken and the consumption of samples is in smaller quantities for every investigation. In medicinal chemistry, the USP (United States Pharmacopeia) and BP (British Pharmacopeia) are directly involved in production as well as in quality testing.

Application of Sofia Plus catheter tip shaping in the treatment of acute middle cerebral artery occlusion: A case control study.

To explore the safety and efficacy of Sofia Plus distal access catheter tip shaping for treatment of acute middle cerebral artery embolism. This single-center retrospective study involved patients eligible for acute embolic middle cerebral artery occlusion from January 2020 to October 2021. They were divided into a shaping and non-shaping group according to whether the Sofia Plus catheter tip was shaped intraoperatively. Baseline data, preoperative Alberta Stroke Program Early Computed Tomography (ASPECT) score, National Institutes of Health Stroke Scale (NIHSS) score, onset-to-admission time, admission-to-puncture time, Sofia Plus-clot time, puncture-to-reperfusion time, surgical approach, and use of a stent for rescue thrombectomy were compared between the 2 groups. Postoperative symptomatic intracerebral hemorrhage and the modified Rankin scale score at the 90-day follow-up were observed. In total, 54 patients were enrolled in this study (shaping group, 26 patients; non-shaping group, 28 patients). Their mean age was 64.8 ± 14.6 years, and the proportion of men was 68.5% (37/54). Successful recanalization was achieved in all patients. There were no differences in the baseline data (age, sex, history, pre-admission ASPECT score, or NIHSS score) between the shaping and non-shaping groups. Patients treated with a shaped Sofia Plus catheter had a shorter Sofia Plus-clot time [median (25th, 75th percentile: 4 (4, 7) vs 10.5 (5.25, 14) min, P = .006] and puncture-to-reperfusion time [16.5 (12, 30.5) vs 26 (16.25, 38.25) min, P = .036]. There were significant differences in the surgical approaches between the 2 groups. The rates of a favorable outcome (57.7% vs 64.3%, P = .62) and postoperative symptomatic intracerebral hemorrhage (7.7% vs 3.6%, P = .60) were not significantly different between the groups. Sofia Plus catheter tip shaping improved catheter trafficability and reduced the operative time. It was safe and effective for treatment of acute middle cerebral artery thrombotic occlusion.

Seizure as the first symptom of cavernous sinus dural arteriovenous fistula: A case report and literature review

Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication associated with a variety of clinical manifestations. The previous literature has rarely reported the occurrence of CS-DAVF with seizures and cerebral hemorrhage, signaling the need for more case reports and literature review in this area. A 62-year-old Chinese female presented with a paroxysmal loss of consciousness, accompanied with involuntary eye movement to the left, chewing issues, salivation at the right corner of the mouth, and bit tongue. The brain computed tomography revealed that the left temporal lobe was hemorrhagic. Brain scan and contrast-enhanced magnetic resonance imaging showed diffuse meningeal enhancement and lesions in the left frontoparietal temporal lobe, insular lobe, and hippocampal head region. Electroencephalography demonstrated continuous emission of spike and slow waves in the left hemisphere. With the aid of digital subtraction angiography, the patient was confirmed with a diagnosis of CS-DAVF draining into the ipsilateral cavernous sinus, intercavernous sinus, contralateral cavernous sinus, left superior ophthalmic vein, left lateral fissure vein, and left pterygoid venous plexus. The fistula was closed with interventional embolization through the femoral vein, and immediate angiography showed complete resolution of CS-DAVF after operation. The patient did not manifest any post-operative complications. This case highlights that the prevention of epilepsy, cerebral hemorrhage, and other serious complications is extremely important for good prognosis, especially in some patients presenting with serious clinical symptoms. It also sheds light on the necessity to consider the diagnosis of CS-DAVF if seizures, although extremely rare, are present.

Large-bore mechanical thrombectomy for intermediate- and high-risk pulmonary embolism: interim outcomes from the European cohort of the FLASH registry

Abstract Background/Introduction Mechanical thrombectomy is utilized for the treatment of acute pulmonary embolism (PE), but reported outcomes are limited in the European patient population. Purpose To report interim results from the European cohort of a large, prospective all-comer registry of mechanical thrombectomy for PE treatment. Methods The FLASH registry is a multinational, prospective, observational study of safety and effectiveness outcomes for PE treatment using a large-bore mechanical thrombectomy system. FLASH is currently enrolling up to 200 patients in Europe. The primary endpoint is a composite of Major Adverse Events (MAEs) within 48 hours, including device-related deaths, major bleeding, and intraprocedural AEs. Additional assessments include invasive hemodynamics, hospital resource usage, and dyspnea improvement. Results Interim results through 48 hours post-thrombectomy are presented for the first 29 patients enrolled in the European cohort across 4 institutions. Mean patient age was 64.9±14.5 years, 51.7% of patients were male, 10.3% were contraindicated for thrombolysis, 51.7% had concomitant deep vein thrombosis, and 79.3% had centrally located thrombus involving one or both main pulmonary arteries. Per ESC guidelines, 58.6% of patients were classified as high-risk. The remaining 41.4% of patients were classified as intermediate-risk, with 31.0% being intermediate-high-risk. Pre-thrombectomy, the median RV/LV ratio from a composite of computed tomography and echocardiography was 1.31 [IQR: 1.08-1.44], and 38.9% of patients who had cardiac index (CI) measured were in cardiogenic shock (CI ≤2 L/min/m²). Procedural characteristics included a median thrombectomy time of 39 minutes [IQR: 26-49]. Extracorporeal membrane oxygenation was used in 6.9% of patients. Post-thrombectomy, the median length of stay in the intensive care unit (ICU) was 1 overnight [IQR: 0-2], and 48.1% of patients required no overnight ICU stay. In addition, hemodynamic variables, vitals, dyspnea symptoms, and reliance on supplemental oxygen all improved significantly post-thrombectomy (Table 1). Acute safety and mortality outcomes were highly favorable following the procedure (Table 2). All patients survived through 48 hours post-thrombectomy. There were no MAEs (0%), no major access site complications (0%), and no device-related Serious AEs (0%) through 48-hour follow-up. Conclusions Interim results from the first 29 patients in the European cohort of the FLASH registry suggest that large-bore mechanical thrombectomy can be safely performed in both intermediate- and high-risk PE patients, with no MAEs or mortalities observed through 48 hours. Significant improvements observed in multiple hemodynamic and dyspnea-related variables further suggest that thrombectomy can offer effective reperfusion treatment for acute PE.

The effect of DOAC-Stop on lupus anticoagulant testing in patients with pulmonary embolism receiving direct oral anticoagulants

Abstract Background Direct oral anticoagulants (DOACs) are widely used as first-line treatment for pulmonary embolism (PE) but may cause false positive lupus anticoagulant (LA) based on prolongation diluted Russell's viper venom time (dRVVT) or activated partial thromboplastin time (aPTT). Exclusion of antiphospholipid syndrome is recommended in PE patients since this disease requires warfarin, not DOACs. Aims We evaluated whether the use of DOAC-Stop, an agent reversing in vitro effects of DOACs, allows for reliable LA testing in PE patients on DOACs. Methods We assessed 172 consecutive PE patients aged 48 ± 14 years (50.6 % women) screened for antiphospholipid syndrome according to ISTH guidelines. Blood was collected 1–24 h since intake of a DOAC, i.e. rivaroxaban (n=81, 47.1%), dabigatran (n=53, 30.8%) and apixaban (n=38, 22.1%). LA testing was performed after DOAC-Stop (Haematex Research, Hornsby, Australia) treatment. Positive LA was reported when the normalized (patient/standard plasma clotting time) LA screening and screening (LA1)/confirmation (LA2) ratios exceeded 1.2. Results In screening tests after DOAC-Stop use, the dRVVT remained prolonged in 9 (5.2%) patients including 4 (44.5%) on apixaban, 3 (33.3%) on rivaroxaban and 2 (22.2%) on dabigatran, while the dRVVT LA1/LA2 ratio was abnormal in 7 (4.1%) subjects: 3 (42.9%) were on apixaban, 3 (42.9%) on rivaroxaban and 1 (14.2%) on dabigatran. In 2 (22,2%) patients the dRVVT LA1/LA2 ratio exceeded 2. The aPTT-LA screening test remained prolonged in 8 (4.6%) patients including 4 (50.0%) on apixaban, 2 (25.0%) on rivaroxaban and 2 (25.0%) on dabigatran, while the aPTT LA1A/LA2A ratio was abnormal in 5 (2.9%) patients: 3 (60.0%) on apixaban, 1 (20.0%) on rivaroxaban and 1 (20.0%) on dabigatran). In 1 (12.5%) patients the aPTT LA1/LA2 ratio exceeded 2. Antiphospholipid syndrome with the presence of LA was diagnosed in 7 (87.5%) patients. False positive LA had 1 (0.6%) patients after the DOAC-Stop use. Conclusion(s) To our knowledge, this is the largest cohort of PE patients on DOACs evaluated for LA, with use of DOAC-Stop, showing reliability of such approach in the real-life setting, with &amp;lt;1% of patients with false positive LA.

Abstract 19175: Anaphylaxis After Alteplase During Treatment of Pulmonary Embolism

Introduction: Anaphylaxis is a rare complication to alteplase, a recombinant tissue plasminogen activator (tPA), during administration for pulmonary embolism (PE). Case Presentation: A 72-year-old male with a history of necrotizing fasciitis, recent below the knee amputation, and concern for metastatic melanoma had been undergoing treatment for an acute DVT with apixaban when he presented with an extensive saddle pulmonary embolism. He was evaluated by a Pulmonary Embolism Response Team (PERT) and classified as high risk (sPESI 2, new right ventricular dysfunction, and hypoxemia) and treated with 50 mg alteplase over two hours. At the end of his infusion, he experienced worsening hypoxemia and sudden hypotension treated with fluid resuscitation and an epinephrine infusion. Hemodynamic instability was thought to be secondary to obstructive shock so an additional 50 mg of alteplase was ordered. After the initial bolus of 10 mg alteplase, the patient demonstrated signs of anaphylaxis. He was initially treated with epinephrine, diphenhydramine, famotidine, methylprednisolone, and lactated ringers for the anaphylactic shock. The patient eventually required the addition of norepinephrine, vasopressin, and methylene blue for resolution of the shock. No additional alteplase was administered and a heparin infusion was resumed for treatment of the pulmonary embolism. He was ultimately successfully weaned off vasopressors and oxygen support with resolution of the pulmonary embolism. Discussion: Cardiac critical care providers should monitor for signs of anaphylaxis when using tPA in the management of PE. The main intervention of anaphylactic shock is administration of epinephrine. Updated guidelines recommend use of intramuscular epinephrine in the setting of anaphylaxis.

Abstract 15011: Recent Trends in Interventional Treatment of Acute Pulmonary Embolism and Their Implications for a National Healthcare System

Introduction: Catheter-directed treatment (CDT) of acute pulmonary embolism (PE) is gaining popularity in Europe, following a trend that originated earlier in the US. For healthcare systems, reimbursement of CDT depends on their clinical benefits along with assessing the impact on hospital costs. Hypothesis-Aims: To estimate how increasing use of CDT, as reflected by prospective US data, may affect costs of PE treatment in the German hospital remuneration system (G-DRG). Methods: We analyzed data from the German nationwide inpatient sample (Federal Statistical Office), covering all hospitalizations for PE, for the years 2018-2019. For the same period, we analyzed prospective patient-level data from the multicenter US registry of the Pulmonary Embolism Response Team (PERT) Consortium. Results: During the study period, 196,167 patients were hospitalized for acute PE in Germany. Of these, 64,056 (33%) had intermediate-risk or high-risk PE, but overall ≤ 1% received CDT. Median reimbursement was є3,572 (IQR, 2,804-5,869), corresponding to є4,088 in inflation-adjusted 2022 currency ($5,678, adjusted for purchase parity power). Of 1,349 patients with intermediate- or high-risk PE included in the US registry in 2018-2019, 284 (21%) received CDT, mostly aspiration thrombectomy (63/1,349; 4.7%), ultrasound-assisted catheter thrombolysis (151; 11.2%), or non-assisted catheter thrombolysis (47; 3.5%). Median length of stay was 4.5 (2.8-8.2) days. Based on current reimbursement rates in the G-DRG, fees for PE treated with aspiration thrombectomy amount to є12,179-15,753, and for catheter-directed thrombolysis (with or without ultrasound) to є9,858-13,829. Considering, (a) the shorter length of stay; (b) the proportion of patients receiving CDT in the elevated-risk US cohort in 2018-19; and (c) that of intermediate- and high-risk PE in the German PE inpatient sample, average remuneration per patient would rise from currently є4,088 to є4,724 ($6,552). Conclusions: CDT for PE patients at elevated risk would currently lead to a 16% increase in average per-patient hospital costs in Germany. Together with clinical validation of CDT in ongoing studies, these estimates may inform decision making on reimbursement of interventional treatment options.

Abstract 13715: Catheter-Based Therapies in High-Risk Pulmonary Embolism: Outcomes From a Tertiary Referral Center

Introduction: Prompt and effective treatment of pulmonary embolism (PE) is essential to prevent morbidity and mortality. We aim to evaluate and compare the effectiveness of two FDA-approved catheter-based therapies (CBT) for acute high-risk PE: ultrasound-assisted catheter-directed thrombolysis EKOS (EKOS Corporation, Bothell, WA) and Penumbra Indigo aspiration thrombectomy (Penumbra Inc., Alameda, CA, USA). Methods: Patients with acute high-risk submassive or massive PE who underwent CBTs between 09/2014 and 08/2022 at our institution were identified. The primary efficacy outcome was the change in the echocardiographic RV/LV diameter ratio within 48 to 72h of procedure. Results: A total of 189 patients underwent EKOS (n=119) or Penumbra (n=70) for submassive (n=175) and massive (n=14) PE (Table). Both groups had similar demographics and clinical characteristics except for prior DVT. Mean age was 60.6±14.3 years old and 55.6% were male. The RV/LV ratio showed significant improvement post intervention, with 21.2% decrease in the EKOS group (EG) and 35.6% in the Penumbra group (PG). The PG had a greater decrease in RV/LV (median change 0.396 (IQR, 0.347) vs. 0.207 (IQR, 0.306), p&lt;0.001). In the cohort, 25 adverse events were reported (13.2%). The rate of complications did not differ between the 2 groups, with 15.1% in EG and 10% in PG. In terms of bleeding complications, GUSTO moderate bleeding was observed in 8 cases (5 in EG and 3 in PG), while severe bleeding was observed in 3 (2 in EG and 1 in PG), including 1 intracranial hemorrhage in the PG. ICU admissions were higher in the PG (p&lt;0.001), but median hospital and ICU stays were comparable. No significant difference was found in the rate of in-hospital mortality (2.5% in EG, 4.3% in PG, p=0.672). Conclusion: Both CBT options are promising for treating submassive PE, with efficacy outcomes favoring Penumbra thrombectomy. Longer follow-up and randomized controlled trials are needed for definitive conclusions.