Treatment Of Pulmonary Embolism Research Articles

The Use of Artificial Intelligence Technology in the Detection and Treatment of Pulmonary Embolism at a Tertiary Referral Center

The Use of Artificial Intelligence Technology in the Detection and Treatment of Pulmonary Embolism at a Tertiary Referral Center

Ultrasound-accelerated catheter-directed thrombolysis: a new tool for the treatment of pulmonary embolism in Brazil

Ultrasound-accelerated catheter-directed thrombolysis: a new tool for the treatment of pulmonary embolism in Brazil

In silico evaluation of pharmacokinetic parameters, delivery, distribution and anticoagulative effects of new 4,7-dihydroxycoumarin derivative

In this study, pharmacological profiling and investigation of the anticoagulant activity of the newly synthesized coumarin derivative: (E)-3-(1-((4-hydroxy-3-methoxyphenyl)amino)ethylidene)-2,4-dioxochroman-7-yl acetate (L) were performed. The obtained results were compared with the parameters obtained for Warfarin (WF), which is a standard good oral anticoagulant. The estimated high binding affinity of L toward plasma proteins (PPS% value is > 90%) justifies the investigation of binding affinity and comparative analysis of L and WF to Human Serum Albumin (HSA) using the spectrofluorimetric method (296, 303 and 310 K) as well as molecular docking and molecular dynamics simulations. Compound L shows a very good binding affinity especially to the active site of WF (the active site I -subdomain IIA), quenching HSA fluorescence by a static process. Also, the finite element smeared model (Kojic Transport Model, KTM), which includes blood vessels and tissue, was implemented to compute the convective-diffusion transport of L and WF within the liver. Finally, compound L shows a high degree of inhibitory activity toward the VKOR receptor comparable to the inhibitory activity of WF. Stabilization and limited flexibility of amino acid residues in the active site of the VKOR after binding of L and WF indicates a very good inhibitory potential of compound L. The high affinity of the L for the VKOR enzyme (Vitamin K antagonist), as well as the structural similarity to commercial anticoagulants (WF), provide a basis for further studies and potential application in the treatment of venous thrombosis, pulmonary embolism and ischemic heart disease. Communicated by Ramaswamy H. Sarma

Abstract P3021: Circulating Exosomal MicroRNAs As Biomarkers For Pulmonary Embolism

Pulmonary Embolism (PE) is the third leading cause of death worldwide. Current treatment for PE, including thrombolytics and anticoagulants, have serious side effects. Protein and RNA biomarkers presently used to diagnose PE do not have the necessary specificity or sensitivity. Therefore, discovery of predictive biomarkers for therapeutic effects and adverse outcomes is imperative. MicroRNAs (miRNAs) are known to regulate gene expression networks and their expression levels reflect the physiological state of their cell of origin. By investigating these circulating miRNAs, we can gain valuable insight into the state of the damaged cells or tissue. Here, we innovated a novel methodology to isolate exosomes from patient platelet-free plasma that provides better yield of both exosomes and their RNA content. We are the first to stratify the PE patient samples according to clinical severity (low-risk, sub-massive, massive PE) and analyze the correlations of the exosomal miRNA biomarkers with PE severity. We found that exosomes from PE patients are more heterogeneous, lower in concentration and larger in size compared to healthy controls. Further, exosomes from PE patient samples pack more RNA than healthy controls. With the results from ongoing miRNA sequencing, we will be able to identify miRNAs and other short non-coding RNAs as potential diagnostic biomarkers that best correlate with PE severity. Validation and predictive studies using qRT-PCR will push the frontiers on circulating small RNA biomarkers in PE and other cardiovascular diseases. Finally, network analysis on the potential RNA biomarkers will provide information for future studies on disease mechanisms and therapeutics development.

Interventional therapies in acute pulmonary embolus-current trends and future directions.

Venous thromboembolic disease presenting with acute pulmonary embolus (PE) can be treated in a variety of ways from anticoagulation as an outpatient to surgical embolectomy with many new interventional therapies being developed. Mortality in these patients can be as high as 50% and many of these treatments are also considered to be high risk. Early involvement of a multidisciplinary team and patient risk stratification can aid management decisions in these complex patients who can suddenly deteriorate.In this review, we summarise the evidence behind new and developing interventional therapies in the treatment of high and intermediate-high risk PE including catheter-directed thrombolysis, pharmacomechanical thrombolysis, thromboaspiration and the growing role of extracorporeal membrane oxygenation in the stabilisation and management of this cohort of patients.

Indigo® Aspiration System for thrombectomy in pulmonary embolism.

Anticoagulation is mainstay therapy for patients with acute pulmonary embolism while systemic thrombolysis is reserved for those with hemodynamic instability. Over the last decade, percutaneous interventional options have entered the landscape aimed to achieve rapid pharmacomechanical pulmonary artery recanalization. The Penumbra Indigo® Aspiration System (PenumbraInc., CA, USA) is a USFDA-approved large-bore aspiration thrombectomy device for the treatment of pulmonary embolism. Recent data has demonstrated improved radiographic end points with low rates of major adverse events in cases of intermediate-risk pulmonary embolism. In this review article, we outline device technology, applications, evidenceand future directions.

Changes in Healthcare Utilization During the COVID-19 Pandemic and Potential Causes-A Cohort Study From Switzerland.

Objectives: To describe the frequency of and reasons for changes in healthcare utilization in those requiring ongoing treatment, and to assess characteristics associated with change, during the second wave of the pandemic. Methods: Corona Immunitas e-cohort study (age ≥20years) participants completed monthly questionnaires. We compared participants reporting a change in healthcare utilization with those who did not using descriptive and bivariate statistics. We explored characteristics associated with the number of changes using negative binomial regression. Results: The study included 3,190 participants from nine research sites. One-fifth reported requiring regular treatment. Among these, 14% reported a change in healthcare utilization, defined as events in which participants reported that they changed their ongoing treatment, irrespective of the reason. Reasons for change were medication changes and side-effects, specifically for hypertension, or pulmonary embolism treatment. Females were more likely to report changes [Incidence Rate Ratio (IRR) = 2.15, p = 0.002]. Those with hypertension were least likely to report changes [IRR = 0.35, p = 0.019]. Conclusion: Few of those requiring regular treatment reported changes in healthcare utilization. Continuity of care for females and chronic diseases besides hypertension must be emphasized.

Surgical Treatment of Pulmonary Embolism Associated with COVID-19: First-Hand Experience

INTRODUCTION: Venous thromboembolic complications occupy one of the central positions in the structure of complications associated with CoronaVirus Disease 2019 (COVID-19). Characterized by high epidemiological threshold values, as well as an atypical clinical picture, they determine the need for new approaches to early diagnosis and active treatment. Surgical treatment of pulmonary embolism in itself is an extremely controversial method of reperfusion of the pulmonary arterial bed. Concerning pulmonary embolism associated with a new coronavirus infection, we did not find a single clinical case reported in the available literature. The article considers a clinical case of surgical treatment of pulmonary embolism against the background COVID-19 infection, demonstrates a comprehensive approach to treatment and describes peculiarities of the clinical picture.
 CONCLUSION: Based on the presented case, one should note the importance of the anticoagulant therapy in a group of people with a virus-specific intervention to prevent recurrence of thromboembolic complications. Complex surgical treatment in combination with the proposed methods of anesthesiological support are the methods of choice in a group of people at intermediate-high and high risk of early cardiac death.

Revised Paradigm for Acute Pulmonary Embolism Prognostication and Treatment.

Revised Paradigm for Acute Pulmonary Embolism Prognostication and Treatment.

Response to Letter to the Editor regarding the article “Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism”

Response to Letter to the Editor regarding the article “Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism”

Comment: Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism

Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary EmbolismJournal of the Society for Cardiovascular Angiography & InterventionsVol. 2Issue 1100453PreviewThere is significant debate on whether large-bore thrombectomy (LBT) or catheter-directed thrombolysis (CDT) is superior for the treatment of intermediate- and high-risk pulmonary embolism (PE) while employing an early invasive strategy through endovascular therapies. Full-Text PDF Open Access Feroze et al1Feroze R. Arora S. Tashtish N. et al.Comparison of large-bore thrombectomy with catheter-directed thrombolysis for the treatment of pulmonary embolism.J Soc Cardiovasc Angiogr Interv. 2023; 2100453Google Scholar retrospectively investigated important problem in contemporary pulmonary embolism (PE) practice by demonstrating that there was no difference in mortality and rehospitalization rates in patients with intermediate-to-high-risk (IHR) PE treated with large-bore thrombectomy compared with those in patients treated with catheter-directed thrombolysis (CDT). Furthermore, both treatment approaches for PE were similar concerning safety. Given the scarcity of randomized data in this setting and inconclusive evidence base regarding hard clinical end points,2Harvey J.J. Huang S. Uberoi R. Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism.Cochrane Database Syst Rev. 2022; 2022: CD013083Google Scholar,3Pietrasik A. Gąsecka A. Szarpak Ł. et al.Catheter-based therapies decrease mortality in patients with intermediate and high-risk pulmonary embolism: evidence from meta-analysis of 65,589 patients.Front Cardiovasc Med. 2022; 9861307Crossref Scopus (0) Google Scholar we would wish to complement the authors' findings with our own recently published retrospective data.4Giunio L. Lozo M. Borovac J.A. Bradaric A. Zanchi J. Miric D. Feasibility and safety of catheter-directed thrombolysis via superficial cubital vein for the treatment of acute massive and submassive pulmonary embolism.Postepy Kardiol Interwencyjnej. 2021; 17: 389-397Google Scholar In our cohort of patients presenting with IHR acute PE, we performed CDT through the superficial cubital vein using a standard pigtail catheter and administering alteplase locally. This method had a robust effect on hemodynamics because it significantly reduced SPAP, and mean PAP, and improved mean systemic perfusion pressure at 12 hours after intervention with a concomitant reduction in the Miller score and index, both reflecting the angiographic severity of pulmonary artery obstruction and perfusion. Of importance, the rates of adverse events, particularly bleeding, were low with 2 bleeding events of which only 1 required the transfusion of 1 unit of packed red blood cells. Furthermore, procedural success was 100% with no intracranial hemorrhage, access-site bleeding, or death events. However, no comparator was available in our study. Taken together, data from the study by Feroze et al1Feroze R. Arora S. Tashtish N. et al.Comparison of large-bore thrombectomy with catheter-directed thrombolysis for the treatment of pulmonary embolism.J Soc Cardiovasc Angiogr Interv. 2023; 2100453Google Scholar and our own suggest that CDT in patients with IHR acute PE is complementary to mechanical thrombectomy and is equally safe and effective procedure that can be successfully performed by cannulating either small or large veins by experienced operators. This is exquisitely important from the pharmacoeconomic standpoint. An option to use readily available catheters outside of dedicated thrombolytic or thrombectomy systems may provide significant economical savings, especially in resource-limited health care systems. Finally, both interventional approaches have a great potential to help a large proportion of patients with PE, and a transcubital access is also a feasible option in this scenario. However, as Feroze et al1Feroze R. Arora S. Tashtish N. et al.Comparison of large-bore thrombectomy with catheter-directed thrombolysis for the treatment of pulmonary embolism.J Soc Cardiovasc Angiogr Interv. 2023; 2100453Google Scholar rightly conclude, adequately powered randomized studies that would examine percutaneous thrombectomy versus CDT and OMT are needed to confirm the clear signal of benefit associated with catheter modalities. Finally, these observations should be put in the context with the recently published consensus statement on percutaneous therapies in acute PE, stipulating that CDT-based strategies should be considered in all cases of IHR acute PE in whom systemic thrombolysis is contraindicated or failed or there was a hemodynamic deterioration despite full therapeutic anticoagulation.5Pruszczyk P. Klok F.K. Kucher N. et al.Percutaneous treatment options for acute pulmonary embolism: a clinical consensus statement by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function and the European Association of Percutaneous Cardiovascular Interventions.EuroIntervention. 2022; 18: e623-e638Crossref Scopus (1) Google Scholar

Tenecteplase: A Review of Its Pharmacology and Uses.

Tenecteplase: A Review of Its Pharmacology and Uses.

Probability-Based Two-Stage CNN for Pulmonary Embolism Detection in Computed Tomography Pulmonary Angiography

Pulmonary embolism (PE) can impede the normal flow of blood, which can result in reduced oxygen levels in vital organs and be life-threatening. Therefore, early detection and treatment of PE can effectively reduce mortality. Computed tomography pulmonary angiography (CTPA) is the clearest and most immediate tool available for PE diagnosis. With an increase in the CTPA image quality and number of slices, physician fatigue associated with interpreting these images during the diagnostic process has also increased. Therefore, this study proposes a modified two-stage convolutional neural network-based approach to automatically detect areas suspected of containing PE in CTPA images to reduce the burden of diagnosis on doctors. The main functions for eliminating false positives include principal component analysis, enlarged feature map (EFM), and probability-based anchor point extraction (PAE). Experimental results showed that although EFM can slightly improve the accuracy for small-object detection, it significantly increases the time required for training. PAE can reduce the training time and slightly improve detection accuracy. But the simultaneous use of EFM and PAE can significantly increase sensitivity (10.57%) with an increase of only 29 min in the training time.

Veno-arterial extracorporeal membrane oxygenation versus standard medical management for massive pulmonary embolism.

There is limited research on the use and outcomes of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment for massive pulmonary embolism (PE). This study compared VA-ECMO treatment for massive PE versus patients treated medically. Patients diagnosed with massive PE at one hospital system were reviewed. VA-ECMO and non-ECMO groups were compared by t test and Chi-square. Mortality risk factors were identified by logistic regression. Survival was assessed by Kaplan Meier and propensity matching of groups. Ninety-two patients were included (22 VA-ECMO and 70 non-ECMO). Age (OR 1.08, 95% CI 1.03-1.13), arterial SBP (OR 0.97, 95% CI 0.94-0.99), albumin (OR 0.3, 95% CI 0.1-0.8), and phosphorus (OR 2.0, 95% CI 1.4-3.17) were independently associated with 30-day mortality. Alkaline phosphate (OR 1.03, 95% CI 1.01-1.05) and SOFA score (OR 1.3, 95% CI 1.06-1.51) were associated with 1-year mortality. Propensity matching showed no difference in 30-day (59% VA-ECMO versus 72% non-ECMO, p = 0.363) or 1-year survival (50% VA-ECMO versus 64% non-ECMO, p = 0.355). Patients treated with VA-ECMO for massive PE and medically treated patients have similar short- and long-term survival. Further research is needed to define clinical recommendations and benefits of intensive therapy such as VA-ECMO in this critically ill population.

Surgical treatment of a patient with pulmonary embolism after a new coronavirus infection

Venous thromboembolic complications (VTC) occupy one of the central positions in the structure of complications associated with a new coronavirus infection. Characterized by high epidemiological thresholds, as well as an atypical clinical picture, they determine the search for new approaches to early diagnosis and active treatment. Surgical treatment of pulmonary embolism, in itself, is an extremely controversial method of reperfusion of the pulmonary arterial bed basin. If we talk about pulmonary embolism associated with the new coronavirus infection, then we have not found a single described clinical case in the literature available to us. The article presents the first experience of complex treatment of subacute pulmonary embolism that developed against the background of COVID-19. The obtained treatment results demonstrate the need to develop a unified treatment protocol at the intersection of interdisciplinary areas, which will help to find answers to the post.

Outcomes of catheter-directed thrombolysis versus systemic thrombolysis in the treatment of pulmonary embolism: a meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) versus systemic thrombolysis (ST) in the treatment of pulmonary embolism (PE). The Cochrane Library, PubMed, and Embase databases were searched to collect the literature on the comparison of the results of CDT and ST in the treatment of PE from the beginning of their records to May 2020, and meta-analysis was performed by STATA software (version 15.1). Using standardized data-collection forms, the authors screened the studies and independently extracted data, and assessed the quality of the studies using the Newcastle-Ottawa Scale for cohort studies. Cohort studies that examined the following results were included in the current study: in-hospital mortality, all-cause bleeding rate, gastrointestinal bleeding rate, intracranial hemorrhage rate, the incidence of shock, and hospital length of stay. A total of eight articles, with 13,242 participants, involving 3962 participants in the CDT group and 9280 participants in the ST group were included. CDT compared with ST in the treatment of PE can significantly affect in-hospital mortality rate [odds ratio (OR) = 0.41, 95% CI: 0.30-0.56, P < 0.05], all-cause bleeding rate (OR = 1.20, 95% CI: 1.04-1.39, P = 0.012), gastrointestinal bleeding rate (OR = 1.43, 95% CI: 1.13-1.81, P = 0.003), the incidence of shock (OR = 0.46, 95% CI: 0.37-0.57, P < 0.05), and hospital length of stay [standard mean difference (SMD) = 0.16, 95% CI: 0.07-0.25, P < 0.05]. However, there was no significant effect on intracranial hemorrhage rate in patients with PE (OR = 0.70, 95% CI: 0.47-1.03, P = 0.070). CDT is a viable alternative to ST in the treatment of PE, as it can significantly reduce in-hospital mortality rate, all-cause bleeding rate, gastrointestinal bleeding rate, and incidence of shock. However, CDT may prolong hospital length of stay to a certain extent. Further research is needed to evaluate the safety and efficacy of CDT and ST in the treatment of acute PE and other clinical outcomes.

Interventional treatment and multidisciplinary management strategies for acute pulmonary embolism

Die interventionelle Therapie der akuten Lungenembolie bietet großes Potenzial zur Senkung von Morbidität und Mortalität ausgewählter Patientinnen und Patienten mit intermediär-hohem und hohem Risiko. In diesem Positionspapier wird die aktuelle Datenlage zusammengefasst. Ferner wird die klinische Entscheidungsfindung mit konsentierten Kernaussagen und Flow-Charts unterstützt. Patienten mit akuter Lungenembolie mit intermediär-hohem oder hohem Risiko sollten demnach unmittelbar nach Diagnosestellung einem multidisziplinären Lungenembolieteam (LET) zur Risikostratifikation vorgestellt werden. Für die proaktive Zusammenstellung des Teams sollten die Expertise und die Ressourcen vor Ort berücksichtigt werden. Die Etablierung multidisziplinärer LETs mit klarer Organisation und standardisierten Abläufen kann den Einsatz der lokal vorhandenen Behandlungsoptionen verbessern. Das Ziel des LET ist eine repetitive Risiko-Nutzen-Abwägung des Gesamtmortalitätsrisikos unter Berücksichtigung des LE-Schweregrades, der Hämodynamik und des Gasaustauschs im zeitlichen Verlauf, sowie des Nutzen-Risiko-Verhältnisses einer Intervention (pharmakodynamisch, katheterbasiert, operativ). Die katheterbasierte, interventionelle Therapie der akuten Lungenembolie ist zu erwägen bei manifester, therapierefraktärer Kreislaufinstabilität, nach erfolgloser systemischer thrombolytischer Behandlung sowie bei hohem Blutungsrisiko und Kontraindikation(en) gegen eine systemische Thrombolyse. Die letzte Entscheidung, ob und wenn ja welche Intervention durchgeführt wird, sollte durch ein LET getroffen werden.

Retrograde pulmonary embolectomy performed without aortic cross-clamping and closed left-sided heart chambers

Despite recent diagnostic and surgical management advances in massive pulmonary embolism (PE) treatment, the prognosis of patients is still unfavorable. The current surgical technique is direct antegrade embolectomy using cardiopulmonary bypass and beating heart, without cardioplegic arrest and hypothermia. A significant disadvantage of this approach is the inability to evacuate distally located thrombotic substances. Several authors offer a solution to these problems by applying retrograde pulmonary perfusion or retrograde pulmonary embolectomy. In 2017 Hussain provided a simplified method for performing retrograde perfusion without left atriotomy. In 2019, we served emergency procedures similar to Hussain’s in two patients with massive PE. As an adjunct, we did them on normothermia beating heart and without aortic clamping.

P377 PERCUTANEOUS TREATMENT OF INTERMEDIATE AND HIGH–RISK PULMONARY EMBOLISM: A CASE REPORT

Abstract Pulmonary embolism is the third most frequent cardiovascular pathology, with an incidence of 100–200 cases for 100.000 inhabitants and is one of the main causes of mortality, morbidity and hospitalizations. Systematic thrombolysis represents the treatment of first choice in high–risk/high–intermediate–risk patients who experience hemodynamic instability, however there are absolute and relative contraindications that do not allow its use in all patients: in these cases, percutaneous catheter treatment can be attempted. A hypertensive and obese 84–year–old woman arrives at the emergency room with the onset of chest pain associated with dyspnea. In the emergency room, high levels of D–Dimer and highly sensitive Troponin T are found, therefore cardiological advice is requested. The echocardiogram shows severe dilatation of the right ventricle with McConnel sign, D–Shape and multiple thrombotic formations in the right atrium. On the advice of the consultant cardiologist, a pulmonary CT angiography is performed with evidence of thromboembolism of the main arterial trunks, massive at the level of the distal juxta–hilar portions. Therefore, high–intermediate–high risk pulmonary embolism is diagnosed and the patient is transferred to the ICU for proper treatment. Despite the infusion therapy with sodium heparin, there is a sudden worsening of the clinical and hemodynamic picture: thus, in the light of the impossibility of performing a rescue thrombolysis due to the recent patient’s femoral fracture, it is decided to perform a percutaneous treatment by thrombectomy, using an “INARI” thrombus–aspirator catheter positioned to the right femoral route. Pulmonary angiography reveals thrombotic sub–occlusion of booth main branches. Five aspiration cycles are performed, two of which in the right pulmonary artery and the remaining three in the left pulmonary artery. Control angiography shows reperfusion of the left lower lobe and partial reperfusion of the left upper lobe, while partial reperfusion of the right upper lobe is found on the right. Abundant thrombotic and partly fibrous material is found during aspiration. After the 5th cycle, cardio–circulatory arrest occurs and despite the resuscitation maneuvers, the patient dies. At present, percutaneous treatment in acute pulmonary embolism is still scarcely used in daily clinical practice, but it will certainly play an important role in the near future as a valid therapeutic alternative .

Home treatment versus early discharge for the outpatient management of acute pulmonary embolism: A non-interventional, post-hoc cohort analysis

IntroductionWe prospectively investigated whether home treatment of pulmonary embolism (PE), is as effective and safe as the recommended early discharge management in terms of outcomes at 3 months. MethodsWe performed a post hoc analysis of prospectively and consecutively recorded data in acute PE patients from a tertiary care facility between January 2012 and November 2021. Home treatment was defined as discharge to home directly from the emergency department (ED) after <24 h stay. Early discharge was defined as in-hospital stay of ≥24 h and ≤48 h. Primary efficacy and safety outcomes were a composite of PE-related death or recurrent venous thrombo-embolism, and major bleeding, respectively. Outcomes between groups were compared using penalized multivariable models. ResultsIn total, 181 patients (30.6 %) were included in the home treatment group and 463 (69.4 %) patients in the early discharge group. Median duration of ED stay was 8.1 h (IQR, 3.6–10.2 h) in the home treatment group, and median length of hospital stay was 36.4 h (IQR, 28.7–40.2) in the early discharge group. The adjusted rate of the primary efficacy outcome was 1.90 % (95 % CI, 0.16–15.2) vs 2.05 % (95 % CI, 0.24–10.1) for home treatment vs early discharge (hazard ratio (HR) 0.86 (95 % CI, 0.27–2.74). The adjusted rates of the primary safety outcome did not differ between groups at 3 months. ConclusionsIn a non-randomized cohort of selected acute PE patients, home treatment provided comparable rates of adverse VTE and bleeding events to the recommended early discharge management, and appears to have similar clinical outcomes at 3 months.