Massive Pulmonary Embolism Research Articles

Advances in Percutaneous Management of Pulmonary Embolism.

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.

Acute Massive and Submassive Pulmonary Embolism: Historical Considerations/Surgical Techniques of Pulmonary Embolectomy/Novel Applications in Donor Lungs with Pulmonary Emboli.

Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery. The advent of cardiopulmonary bypass, extracorporeal membrane oxygenation, and computed tomography pulmonary angiogram has allowed rapid diagnosis and made surgical pulmonary embolectomy a relatively safe procedure that should be considered when indicated. Pulmonary emboli in donor lungs, often get rejected for transplantation. Ex vivo lung perfusion is among newly available technology with the ability to not only recondition marginal lungs but also treat donor lung pulmonary embolisms, effectively increasing the donor pool.

Management of Massive Pulmonary Embolism.

Pulmonary embolism is a potentially lethal manifestation of venous thromboembolic disease. It is one of the three main causes of cardiovascular morbidity and mortality in developed countries. Over the years, better diagnostic and risk stratification measures were implemented. A generous range of new treatment options is becoming available, particularly for management of massive pulmonary embolism. Nonetheless, clinicians often face uncertainty in clinical practice due to lack of scientific support for available treatment options. The aim of this article is to review management of massive pulmonary embolism.

Progress in interventional radiology treatment of pulmonary embolism: A brief review.

Pulmonary embolism represents a common life-threatening condition. Prompt identification and treatment of this pathological condition are mandatory. In cases of massive pulmonary embolism and hemodynamic instability or right heart failure, interventional radiology treatment for pulmonary embolism is emerging as an alternative to medical treatment (systemic thrombolysis) and surgical treatment. Interventional radiology techniques include percutaneous endovascular catheter directed therapies as selective thrombolysis and thrombus aspiration, which can prove useful in cases of failure or infeasibility of medical and surgical approaches.

The Pulmonary Embolism Response Team: Rationale, Operation, and Outcomes.

The pulmonary embolism response team (PERT) is an institutionally based multidisciplinary team that is able to rapidly assess and provide treatment for patients with acute pulmonary embolism (PE). Intrinsic to the team's structure is a formal mechanism to execute a full range of medical, endovascular, and surgical therapies. In addition, the PERT provides appropriate multidisciplinary follow-up of patients. In the 10 years since the PERT was first introduced, it has gained acceptance in many centers in the United States and around the world. These PERTs have joined together to form an international association, called the PERT Consortium. The mission of this consortium is to advance the diagnosis, treatment, and outcomes of patients with PE. There is considerable evidence that the PERT model improves delivery and standardization of care of PE patients, particularly those patients with massive and submassive PE. However, it is not yet clear whether PERTs improve clinical outcomes. A large prospective database is currently being compiled by the PERT Consortium. Analysis of this database will likely further delineate the role of PERTs in the management of intermediate-to-high risk PE patients and, importantly, help determine in which PE patients PERT may improve clinical outcomes.

Obstructive jaundice syndrome of benign genesis and its surgical treatment

Introduction: Obstructive jaundice in surgical hospitals is relatively common (2.6-23.7%). And it is one of the leader in the liver failure development with the severe homeostasis disorders appearanced. So, the analysis of the results of improving the surgical treatment of obstructive jaundice syndrome of benign genesis has been conducted from 2015 to 2019. Materials and Methods: The results of surgical treatment of 142 patients with cholelithiasis (gallstone disease) complicated by obstructive jaundice of benign genesis were analyzed: 95 females (66.9%) and 47 (33.1%) male patients. Patients were divided into two groups (experimental and control) according to the surgery method was used. Results: 5 complications (7.2%) and in 5 patients (7.2%) were fixed in the experimental group. However, only in a single complication was the II degree of severity according to the Clavien-Dindo classification. Control group had more complications cases: 18 (24.7%) in 13 patients (17.8%) ‑ (χ2=7.922, p=0.005). Mortality rate was also different: absent in the main group and 4 cases (5.5%) in the control one because of hepatic-renal failure against the background of severe intoxication (2 cases), massive pulmonary embolism (1 case), and disseminated intravascular coagulation syndrome (1 case).

Mid-term success rate of single stage hybrid ablation of persistent and long-term persistent atrial fibrillation.

Single stage thoracoscopic radiofrequency ablation (RFA) is a treatment method for persistent and long-term persistent atrial fibrillation (AF) offering the possibility for patients otherwise inconsolable by conventional catheter RFA. We present a pilot group of patients after the introduction of the new method at our clinical center. Patients group: A total of 52 patients aged 61.82 ± 9.7 years underwent single stage hybrid ablation (thoracoscopic isolation of pulmonary veins and box lesion followed by catheter verification of the surgical procedure effectivness) for symptomatic persistent and long-term persistent AF with significantly dilated left atrium 57.9 ± 11.0mm in the period September 2016-March 2019. The median duration of the procedure was 232 minutes and the median duration of hospitalization was 10 days. At discharge, 52 patients (100%) had sinus rhythm. 48 of 52 patients (92.3%) had a 6-month follow-up. 41 of 48 (85.4%) and 38 of 44 (86.4%) of patients were AF free at 3-month and 6-month follow-up, respectively. Acute complications were: one left atrial perforation resolved successfully by suture and one transient ischaemic attack without permanent sequelae. Late complications involved one massive pulmonary embolization and an atrioesophageal fistula. There was no periprocedural myocardial infarction or stroke with permanent sequelae. Hybrid thoracoscopic-catheter ablation performed during one procedure is an effective and relatively safe mini-invasive method of treatment for long-term persistent atrial fibrillation.

Massive Embolism: Knife versus PCI.

Pulmonary embolism is the third most common cardiovascular syndrome with an estimated up to 25% of patients presenting with sudden death. For those who survive, a mainstay of management for patients with hemodynamic stability is anticoagulation; however, recommendations and options are rapidly changing for patients with submassive or massive pulmonary embolism with hemodynamic instability. Catheter-based and surgical approaches offer efficacious management options for unstable patients or patients with contraindications to anticoagulation; however, both approaches have inherent benefits and risk. This article seeks to offer a brief review on the recommendations and options for management of pulmonary embolism from both surgical and catheter-based perspectives.

Massive Right Ventricular and Pulmonary Artery Emboli In-Transit after Cardiac Surgery: Consideration of Non-Surgical Treatment

Background:Pulmonary embolism (PE) is a complication of open-heart surgery that accounts for 0.6% of all cases and its mortality rate varies from 50% to 100%. Here, we describe a case of right ventricular and pulmonary artery emboli in-transit. Case report: A 56-year-old female presented with complain of dyspnea and palpitation and history of recent coronary artery bypass graft (CABG) surgery. Edema of the right leg was noted. Trans-esophageal echocardiography (TEE) performed and revealed severe tricuspid regurgitation due to stucking clot in tricuspid valve. A large clot in right ventricle (RV) and right ventricle outflow tract (RVOT) with the size of 55 × 13mm was noted. There was also a clot with the size of 22 × 10mm in right pulmonary artery (RPA). Early in the ICU, patient received 10 units (18mg) of reteplase (IV) over 2 minutes and then 10 units was given with the rate of 1mg/hour after the first dose, with 30 minutes intervals. IV Heparin (18mg/Kg/h) was also co-administered with reteplase.There was no visible clot in RV and pulmonary artery in follow-up echocardiography. Patient transferred to CCU with stable hemodynamics and finally discharged with normal condition. Discussion: Surgery is an alternative in patients with massive PE but our patient had a prior cardiac surgery which re-operation had a high risk for her. Due to massive in-transient emboli of right heart and PA in our patient, we decided to proceed the treatment with reteplase. The patient was monitored carefully for hemodynamics and coagulation parameters and she was discharged without any systemic complication.

Management of High-Risk Pulmonary Embolism: What Is the Place of Extracorporeal Membrane Oxygenation?

Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39–115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.

Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series

Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP <90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient’s clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.

Safety and outcomes of thrombolytic therapy in patients with pulmonary embolism and thrombocytopenia: A systematic review.

Thrombolysis is an established therapeutic modality for patients with high-risk (and some selected intermediate-risk) pulmonary embolism (PE) with hemodynamic instability. Physicians sometimes experience cases where both a high-risk PE and thrombocytopenia coexist. Although thrombocytopenia of < 100 × 103/mm3 is considered a contraindication in patients with ischemic stroke, the safety and outcomes of thrombolysis in patients with acute PE and thrombocytopenia are unknown. This systemic review aimed to pool data on the safety and outcomes of thrombolysis use in patients with PE and platelet count less than 150 × 103/mm3. Patients’ demographics, clinical characteristics, management, type of thrombolytic therapy, and outcomes were extracted and analyzed. Of 283 articles identified through the systematic search, 11 case reports fulfilled the inclusion criteria. The mean age of the patients was 52.27 years, and 54.5% were women. The median platelet level before thrombolysis was 65.50 × 103/mm3. Before thrombolysis was initiated, the lowest and highest platelet levels were 29 × 103/mm3 and 105 × 103/mm3, respectively. Alteplase was used in 10 patients and urokinase in one patient. One patient who had a massive PE died of aspiration pneumonia. Interestingly, no thrombocytopenia-related complications were reported. This systematic review highlights the potential benefits and safety of thrombolysis in patients with acute PE in the context of thrombocytopenia. Nevertheless, data available in the literature concerning this topic are scarce and limited to case reports. More extensive studies on the use of thrombolysis in patients with PE and thrombocytopenia are desperately needed.Systematic review registration: The protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42021286415.

Case Report: Role of transesophageal echocardiography in a patient with an initially misdiagnosed acute pulmonary embolism

Background: For the diagnosis of acute pulmonary embolism, chest computerized tomography (CT) angiography is considered as the gold standard. However, echocardiography could be useful especially in cases of high suspicion with normal CT scan or for patient with hemodynamic instability. Case presentation: We present a case of a 47-year-old man admitted to the intensive care unit with a diagnosis of respiratory failure and hemodynamic instability 24 hours after closed fracture of the right leg. Before his admission, a thoracic CT angiography was done but did not show any sign of acute pulmonary embolism. During the first hours, he presented a bad evolution with a respiratory status which failed to respond to high dose of vasopressor, oxide nitric and ventilatory support. Therefore, due to the poor echocardiographic window, transesophageal echocardiography examination was done in emergency. It revealed high-probability diagnosis of massive pulmonary embolism based on right ventricular dysfunction and the presence of thrombus in the right pulmonary artery. Anticoagulant therapy (non-fractioned heparin) was administrated immediately achieving a favorable clinical outcome with rapid withdrawal of dobutamine, nitric oxide and norepinephrine. Conclusions: This case illustrates the fundamental role of transesophageal echocardiography in a critically ill patient with shock due to high-probability pulmonary embolism. Echocardiography allows the initiation of adequate treatment without further delay.

Association between CHA2DS2-VASc Score and Right Ventricular Dysfunction in Patients with Acute Pulmonary Embolism

Background: Acute right ventricular dysfunction (RVD) is a leading cause of death in the setting of acute pulmonary embolism (PE). Therefore, several studies investigated the predisposing factors of RVD. However, at present, little is known about the clinical predictors of RVD in the patients presented with acute PE.&#x0D; Objective: To assess the association of CHA2DS2-VASc Score with the PE severity, RVD and the in-hospital mortality in patients presented with acute PE.&#x0D; Methods: This study was conducted on 50 patients admitted with acute PE at Tanta University Hospitals. We studied the association of different variables including demographic data, common risk factors, clinical presentation, management and the in-hospital mortality with the PE clinical subgroups (massive, sub-massive and non-massive) based on the severity of clinical presentation and also the association of these variables with the thromboembolic risk (high, moderate and low) based on the CHA2DS2-VASc scores. The independent predictors of the RVD were then investigated by the univariate and multivariate regression analyses.&#x0D; Results: The massive PE presentation was associated with higher CHA2DS2-VASc scores (P value = 0.02). Also, the incidence of RVD was higher among the high risk group of patients (CHA2DS2-VASc scores ≥3) with P value = 0.009. TAPSE, MPI, FAC, and E`/A` ratio were found to be more significant in the high risk group (P value = 0.032, 0.002, 0.007 and 0.001), respectively. The independent predictors of RVD were demonstrated to be tachycardia, lower systolic blood pressure and CHA2DS2-VASc score (P value = 0.022, 0.007, 0.021), respectively. The CHA2DS2-VASc score predicted the presence of RVD with 66.7 % sensitivity and 78.6% specificity as demonstrated by the receiver operating characteristic (ROC) analysis, with area under the curve (AUC) of 0.776 (CI 0.636-0.882, P value &lt; 0.001). This study demonstrated no statistically significant difference between the different risk groups regarding the in-hospital mortality.&#x0D; Conclusion: Being independent of other factors, the CHA2DS2-VASc score can be used as a new, simple, and reliable tool to predict the development of RVD in patients with acute PE.

Role of extracorporeal membrane oxygenation and surgical embolectomy in acute pulmonary embolism.

Purpose of reviewSurgery is an important option to consider in patients with massive and submassive pulmonary emboli. Earlier intervention, better patient selection, improved surgical techniques and the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) have contributed to improve the safety of surgery for pulmonary emboli.Recent findingsVA ECMO is rapidly changing the initial management of patients with massive pulmonary emboli, providing an opportunity for stabilization and optimization before intervention. The early and long-term consequences of acute pulmonary emboli are better understood, in particular with regard to the risks of chronic thromboembolic pulmonary hypertension (CTEPH), an entity that should be identified in the acute setting as much as possible. The presence of chronic thromboembolic pulmonary disease can be associated with persistent haemodynamic instability despite removal of the acute thrombi, particularly if pulmonary hypertension is established. The pulmonary embolism response team (PERT) is an important component in the management of massive and submassive acute pulmonary emboli to determine the best treatment options for each patient depending on their clinical presentation.SummaryThree types of surgery can be performed for pulmonary emboli depending on the extent and degree of organization of the thrombi (pulmonary embolectomy, pulmonary thrombo-embolectomy and pulmonary thrombo-endarterectomy). Other treatment options in the context of acute pulmonary emboli include thrombolysis and catheter-directed embolectomy. Future research should determine how best to integrate VA ECMO as a bridging strategy to recovery or intervention in the treatment algorithm of patients with acute massive pulmonary emboli.

Inhaled Nitric Oxide (iNO) With a Massive Pulmonary Embolism: A Case Report

Massive pulmonary embolism (PE) is a type of complication related to the migration of deep venous thrombi clot to the lungs. Massive PE is associated with a high level of morbidity and mortality due to elevated pulmonary vascular resistance that can cause right ventricular failure, cardiogenic shock, and hypoxemia. This report aims to explain to the readers the efficacy of applying inhaled nitric oxide (iNO) to patients with a massive PE. It also aims to evaluate iNO’s pulmonary vasodilator efficacy for acute PE.

Massive Pulmonary Embolism despite Anticoagulation in a Post-Covid Patient

Massive Pulmonary Embolism despite Anticoagulation in a Post-Covid Patient

Comparison of outcomes and complications in conventional versus ultrasound-accelerated catheter directed thrombolysis for treatment of pulmonary embolism: A systematic review and meta-analysis.

Acute submassive a massive pulmonary embolism are known as leading causes of cardiovascular morbidity and mortality in emergency departments. Choosing the optimal type of catheter directed thrombolysis (CDT) for treatment of pulmonary embolism presents a quandary to the practitioners. To the best of our knowledge, there is no meta-analysis comparing superiority of conventional CDT and ultrasound-accelerated catheter directed thrombolysis (USACDT). Therefore, in this meta-analysis, we aimed to compare conventional CDT with USACDT regarding clinical outcomes and safety profile. A systematic literature search of previous published studies comparing conventional CDT with USACDT regarding clinical outcomes and safety profile was carried out in the electronic databases including MEDLINE, Scopus, EBSCO, Google Scholar, Web of Science, and Cochrane from inception to December 2021. Data were analyzed by comprehensive meta-analysis software (CMA, version 3). The meta-analysis included nine studies with a total of 705 patients. Our meta-analysis showed that there is no significant difference between two groups with respect to pulmonary arterial systolic pressure (SMD: -0.084; 95% CI: -0.287 to 0.12; p: 0.41), RV/LV (SMD: -0.003; 95% CI: -0.277 to 0.270; p: 0.98), and Miller score (SMD: -0.345; 95% CI: -1.376 to 0.686; p: 0.51). Similarly, we found no statistically significant differences between two groups regarding major and minor bleeding (p > .05). Our meta-analysis showed that when compared with USACDT, conventional CDT provides similar clinical and hemodynamic outcomes or safety for treatment of pulmonary embolism without the need for very expensive technologies. However, randomized clinical trials are required to further investigate cost-effectiveness of USACDT in comparison with conventional CDT.

Low-Dose Thrombolysis in an Intermediate High-Risk Submassive Pulmonary Embolism With Right Atrial Thrombus: A Case Report

BACKGROUND: Venous thromboembolism, encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is the third most common acute cardiovascular syndrome. It requires prompt diagnosis and risk-based treatment strategies. CASE: A 47-year-old male, 30-pack-year smoker who recently underwent open reduction and internal fixation of the right femur presented with dyspnea. There was no hemodynamic instability. Twelve-lead electrocardiogram showed sinus rhythm with incomplete right bundle-branch block, and troponin was elevated. Chest x-ray showed dilated right descending pulmonary artery. Two-dimensional echocardiogram revealed right atrial thrombus with right ventricular dysfunction. Computed tomography of the pulmonary artery confirmed massive PE with infarct on the posterobasal segment of the right lower lobe. Venous duplex scan of the lower extremities showed an acute DVT of the right femoral vein, popliteal vein, and peroneal vein. Anticoagulation was started. With a dilemma of a recent surgery in an intermediate high-risk submassive PE, options other than guideline-recommended systemic thrombolysis were considered. A multidisciplinary consensus recommended the administration of low-dose thrombolysis, which later resulted to clinical improvement. CONCLUSION: This is the first documented local case of successful resolution of a right atrial thrombus with pulmonary thrombus and DVT using low-dose thrombolysis, without complications of bleeding, in a patient with contraindications to thrombolysis. With more clinical experience and studies of low-dose recombinant tissue plasminogen activator in this special population, it can offer a promising treatment option. KEYWORDS: pulmonary embolism, submassive, low-dose systemic thrombolysis, contraindication for thrombolysis, alteplase, tPA, right atrial thrombus

Ultrasound-facilitated catheter-directed thrombolysis via dual right upper extremity venous access into the basilic vein in a case of submassive pulmonary embolism

Traditionally, massive, life-threatening pulmonary embolism (PE) has been treated with systemic thrombolytic therapy, whereas submassive and smaller acute PEs have been treated with systemic anticoagulation therapy. Given that thrombolytic therapy is associated with a risk of life-threatening complications, including intracranial hemorrhage, it has not been routinely used or recommended for submassive PEs. In 2017, the Food and Drug Administration (FDA) approved ultrasound-facilitated catheter- directed thrombolysis (USCDT) for acute massive and sub-massive pulmonary embolism. USCDT is primarily performed via jugular or femoral venous access. There have been isolated reports of USCDT performed via upper-extremity venous access. We present a case of ultrasound-facilitated catheter-directed thrombolysis (USCDT) in a submassive PE patient with dual right upper extremity venous access, where both sheaths were advanced into the basilic vein (due to anatomic variation). Based on recent clinical trial data suggesting that shorted duration USCDT is as effective as longer duration, tPA was infused in this case for 6 hours. This intervention strategy can enhance patient comfort with USCDT therapy and can be particularly helpful in patients at high risk of access site complications and those unable to lie supine for a long duration of infusion therapy.