Pulmonary Thromboembolism Recurrence Research Articles

Prognostication of Patients with Pulmonary Thromboembolism with and without Residual Deep Vein Thrombosis: A Subanalysis of the J'xactly Study.

Objectives: It is unclear whether patients with acute pulmonary thromboembolism (PE) with and without residual deep vein thrombosis (DVT) have different prognoses, and there is debate over whether inferior vena cava filters (IVCFs) should be used in conjunction with oral anticoagulants in patients with venous thromboembolism (VTE). Materials and Methods: The J'xactly involved 1,016 patients and was a multicenter, prospective, observational research. In this subanalysis, 419 patients with PE with or without residual DVT who received rivaroxaban with or without IVCFs between February 2016 and April 2018 in Japan were examined. Results: Of 419 patients with PE, 320 had residual DVT. There was no difference between the groups with and without DVT in terms of the percentage of patients who experienced symptomatic PE recurrence (2.8% [9/320] vs. 3.0% [3/99]) or who died from VTE-related complications (0.9% [3/320] vs. 1.0% [1/99]). The percentages of patients with symptomatic PE recurrence were 0% and 3.2%, and the percentages of patients who died from VTE-related causes were 0% and 1.1%, respectively, in the groups with (n=39) and without (n=281) IVCF, albeit not being statistically different. Conclusion: Patients with PE with and without residual DVT did not have a different incidence of symptomatic PE recurrence. These results require additional study to be confirmed.

P420 A CANCER PATIENT WITH PULMONARY THROMBOEMBOLISM: IS IT RIGHT TO APPLY THE CRITERIA FOR DOSE REDUCTION IN THESE PATIENTS?

Abstract A 78 years old woman presented in our cardio–oncology out–patient clinic to renew apixaban treatment plan. In her medical history she was a former smoker, with a chronic kidney disease in IIIb stadium according to KDIGOI guidelines with a creatinine of 1,54 mg/dl, GFR according CKD 32 ml/min/1.73m2 and according Cockcroft e Gault 28 ml/min/1.73m2. In 2010, she had a right lobe pulmonary cancer diagnosis treated in neo–adjuvant with gemcitabine. After chemotherapy, she underwent surgical lobectomy. During hospitalization she had a deep venous thrombosis complicated by pulmonary thromboembolism, heparin sc was given with resolution of the clinical picture. In 2012 she had a recurrence of pulmonary thromboembolism. Heparin and warfarin in a second time was given. In 2016 for cancer disease progression, she underwent various oncological treatments and she found a stability disease with osimertinib and stereotaxic radiotherapy. Warfarin was switched to apixaban low–doses for low weight and chronic kidney disease. In 2021 in osimertinib therapy, cancer was under control. She was continuing low–dose apixaban. One year later, a CT scan demonstrated a disease progression and inferior cava venous thrombosis. A cardiac evaluation in our unit was required: patients was asymptomatic. EKG and Echocardiogram were normal. Apixaban low dose was changed to edoxaban 30 mg. There was a complete vein recanalization. Unfortunately, patient died after 8 months for cancer. It is important, in the direct oral anticoagulation therapy in cancer patient, to consider not only the indication for dose reduction known by the registration studies but also cancer and therapy factors.

Clinical evaluation of retrievable inferior vena cava filters for the prevention of pulmonary thromboembolism

Inferior vena cava filters (IVCFs) have been reported to cause chronic complications. Recently, retrievable IVCFs (r-IVCF) have been increasingly used to prevent acute pulmonary thromboembolism (PTE) and allow retrieval upon reduction of PTE risk. However, the outcomes of their use in Japan remain unknown. This study retrospectively investigated the acute PTE relapse prevention rate, IVCF retrieval attempt rate, retrieval success rate, and long-term prognosis of 197 patients who underwent r-IVCF insertion at our hospital between 2010 and 2018. Subjects had a mean age of 68years and a male-to-female ratio of 1:1. After r-IVCF insertion, the acute PTE prevention rate was 99.5%. The r-IVCF retrieval rate was 55% (108 patients), with a success rate of 99% (107 patients). r-IVCF retrieval was not attempted in 89 cases due to advanced cancer or poor prognosis (41%), loss to follow-up (32%), and long-term indwelling IVCF (17%). The retrieval group had an average observation period of 36months, with their anticoagulation therapy continuation, PTE recurrence, and deep vein thrombosis (DVT) recurrence rates being 64%, 3%, and 4%, respectively. The non-retrieval group had a mean observation period of 21months, with their anticoagulation continuation, PTE recurrence, and DVT recurrence rates being 78%, 3%, and 15%, respectively. DVT recurrence rates increased significantly in the non-retrieval group (p < 0.01). Moreover, 65% of all DVTs occurred centrally from the femoral veins, among which 9% were contraindicated for anticoagulation therapy. IVCF placement significantly prevented acute PTE but promoted recurrent DVTs when not retrieved after risk reduction. Hence, to increase recovery rates, IVCFs be promptly removed when no longer necessary.

Clinical Significance and Prognosis of Right Heart Thrombi Associated With Acute Pulmonary Thromboembolism - Results of a Multicenter Registry of Thrombolysis in Japan.

Thrombolytic therapy is standard treatment in acute pulmonary thromboembolism (PTE) with hemodynamic instability. Although right heart thrombi (RHT) appear to increase mortality in acute PTE, large-scale studies of acute PTE with RHT are scarce.Methods and Results:Patient data (from August 2005 to May 2014) obtained from post-marketing surveillance of thrombolytic therapy using a tissue-type plasminogen activator were analyzed retrospectively. Of the 2,698 confirmed cases of acute PTE who underwent echocardiographic assessment, 166 (6.2%) were diagnosed with RHT. PTE patients with RHT, compared with those without RHT, had higher rates of mortality (20.2% vs. 10.4%, P<0.001), hemodynamic instability (53.0% vs. 37.7%, P<0.001), and PTE recurrence (6.6% vs. 2.3%, P=0.003). When considering PTE-related hemodynamic severity (cardiopulmonary arrest/collapse, massive, submassive, and non-massive), mortality was significantly higher in patients with RHT in the massive (19.8% vs. 7.7%, P=0.002) and submassive (8.0% vs. 2.8%, P=0.018) groups, whereas no significant differences was found between those with and without RHT in the cardiopulmonary arrest/collapse (51.7% vs. 52.1%, P=0.960) and non-massive (1.6% vs. 0%, P=0.596) groups. PTE patients with RHT had higher mortality, severity, and PTE recurrence rates. RHT was particularly associated with worse outcomes in patients with massive or submassive PTE.

D-dimer is a predictor of clot resolution in patients with pulmonary thromboembolism: A retrospective cohort study.

This study assessed predictors of pulmonary thromboembolism (PE) resolution and their implications for clinical outcome. A total of 150 patients with acute PE diagnosed by computed tomography pulmonary angiography (CTPA) were included. All patients received anticoagulant therapy for 3-6 months and were followed-up for at least 2years. d-dimer levels in plasma were assayed at the first admission and during follow-up. The rate of CTPA-confirmed PE resolution was 48.67% at 6 months, 68% at 12months, and 78.67% at 24months. Thirty-nine patients had recurrent thrombosis after anticoagulation therapy was stopped, whereas 93 patients had complete resolution. The initial d-dimer level positively correlated with the pulmonary artery obstruction index (PAOI) (r=0.21; P=0.015), but did not significantly differ between patients experiencing resolution or recurrence. In contrast, the follow-up mean d-dimer level was significantly higher in the recurrent group (P<0.001), and this level was an independent risk factor for recurrent PE after the termination of anticoagulation treatment (OR 1.003, 95%CI 1.002 to 1.004; P<0.001). Higher initial thromboembolic burden measured by PAOI was associated with residual thromboemboli (P=0.004) and recurrence (P=0.03), but was not an independent risk factor for either. Elevated d-dimer is an independent risk factor for PE recurrence. A higher initial thromboembolic burden may be associated with unresolved thromboemboli or recurrence.

Late Clinical Outcomes of Hybrid Catheter Intervention for Acute Massive Pulmonary Thromboembolism.

Purpose: We aimed to investigate the long-term outcomes of patients undergoing hybrid catheter intervention for acute massive pulmonary thromboembolism.Material and Methods: Twenty-five patients with hemodynamic impairment were treated with mechanical thrombus fragmentation, an intrapulmonary injection of mt-PA, and manual clot aspiration between August 1999 and June 2002. All patients were discharged after the procedure. Patients’ statuses were checked by medical record examinations and telephone interviews. The median follow-up was 141 months (115-168 months).Results: Ten patients died during follow-up, five for malignancy, three for septic shock, one for cerebral infarction, and one for heart failure. One patient had recurrence of pulmonary thromboembolism because of drug withdrawal by self-judgment. No chronic pulmonary thromboembolism was observed. The 1-year, 5-year, and 10-year survival rates were 87.5 ±6.8%, 83.3±7.6%, and 74.5±9.0%, respectively.Conclusion: Patients who undergo hybrid catheter intervention for acute massive pulmonary thromboembolism show good long-term outcomes.

Long-term results of low-dose tissue plasminogen activator therapy in acute pulmonary embolism

Recombinant tissue plasminogen activator (rt-PA) is the most commonly used thrombolytic agent in patients with high risk and intermediate to high mortality risk acute pulmonary embolism (PE). Clinical trials have...

Recurrent Venous Thromboembolism as the Initial Clinical Presentation of Gastric Cancer: A Case Report

Pulmonary thromboembolism (PTE) is a clinically critical disease, misdiagnosis or delayed diagnosis of which can lead to increased rate of mortality. For prevention of recurrence of PTE, recognition of its risk factors or underlying diseases is of great importance. PTE is common in patients with cancer and has high morbidity and mortality rates. Although cancer is a lethal condition, PTE accelerates death in these patients. In the current study, we reported the case of a 50-year-old male presenting with dyspnea, pleuritic chest pain, and non-massive hemoptysis indicating pulmonary embolism. Anticoagulant therapy was initiated, but after 12 days of treatment, new deep vein thromboses in the left upper and right lower limbs were diagnosed. However, no specific risk factors or laboratory abnormalities were detected. History of weight loss during the recent months encouraged further investigation for ruling out malignancy, which led a diagnosis of gastric adenocarcinoma. He did not have any complaints of gastrointestinal disorders.

Impacto de tres años de experiencia en tromboendarterectomía pulmonar

MotivationTo describe clinical experience of a series of cases of adult patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy. MethodsDescriptive retrospective study of eight adults who underwent pulmonary thromboendarterectomy at the Fundación Cardiovascular de Colombia between February 2010 and April 2013. Results5 women and 3 men were assessed, with an average age of 45±18 years, with avergae baseline data of SpO2 92±2%, PaO2/FiO2 244±82, PaCO2 28.8±3.4mmHg, average pukmonary pressure of 53±11mmHg and pulmonary vascular resistance (PVR) of 999±414dyn/s/cm−5. On the third postoperative day one patient required veno-arterial extracorporeal membrane oxygenation (ECMO) during 11 days. At 4±1 days after pulmonary thromboendarterectomy, PVR decreased 71±21% with regards to baseline value (p=0.002, IC 95%) and pulmonary pressure was reduced to 32±27mmHg (p=0.001). Baseline SpO2 increased 96±3%. Survival rate was 100% after 24 months of follow-up, without readmissions or recurrence of pulmonary thromboembolism. ConclusionsInstitutional results were adequate in the short and medium term. Cases with reperfusion edema, the alternative of ECMO as an extracorporeal life support is imperative.

Use of new oral anticoagulants and pulmonary thromboembolism recurrence secondary to Paget–Schroetter syndrome: A case report

Introduction: the “effort” thrombosis or Paget–schroetter syndrome is an unusual form of upper limb deep venous thrombosis. the current management of this syndrome is surgical and to this date, there is no evidence of the anticoagulant therapy effectiveness. case report: We describe a case of a young Japanese male with pulmonary embolism secondary to Paget–schroetter. the patient was treated with rivaroxaban for the pulmonary embolism and no surgical intervention was done. After a follow-up at 6 and 12 months, there was no recurrence of any thrombotic event. conclusion: We described a clinical scenario in which the use of new oral anticoagulants for the treatment of a pulmonary embolism prevents the recurrence of an upper limb thrombosis secondary to Paget–schroetter syndrome. Even though there is no evidence in favor of using new oral anticoagulants for upper limb thrombosis, the current reports proves its successful use.

Surgical removal of vena cava filter located on the right ventricle associated with bilateral pulmonary thromboendarterectomy case report

Background The use of vena cava filter has been broadly indicated for the prevention of pulmonary thromboembolism (PTE) in patients with contraindication for the use of anticoagulants, PTE recurrence during anticoagulation, prophylactic and temporary use in surgical patients with high risk of thromboembolism, and with contraindication for anticoagulation. This is a procedure of easy execution and low risk of complications. However, cases have been reported of the device migration to cardiac chambers with high morbidity and risk of death caused by arrhythmias, tricuspid valve insufficiency, cardiac tamponade, and cardiogenic shock. We are reporting the case of a patient submitted to neurosurgery who developed profound venous thrombosis immediately after surgery. Due to the formal contraindication for anticoagulation, she was submitted to a vena cava filter engraft.

Patient with a Massive Idiopathic Thrombosis in the Inferior Vena Cava

A 50 year-old man with no significant medical history was admitted for dyspnea and left femoral swelling. Contrast-enhanced computed tomography revealed pulmonary thromboembolism (PTE) and a thrombus in the inferior vena cava (IVC). The thrombus extended from the proximal IVC to the left popliteal vein. Therefore, we decided that an IVC filter insertion was difficult to indicate. Urgent IVC and peripheral vein thrombectomy was performed under cardiopulmonary bypass. On postoperative day 1, venous ultrasonography showed residual deep vein thrombosis in the left external iliac-femoral vein and the popliteal vein. The IVC filter insertion was performed to prevent the recurrence of PTE.

Efficacy and Safety of Low Dose Recombinant Tissue-Type Plasminogen Activator for the Treatment of Acute Pulmonary Thromboembolism: A Randomized, Multicenter, Controlled Trial

BackgroundOptimal dosing of the recombinant tissue-type plasminogen activator (rt-PA) is important in treating pulmonary thromboembolism (PTE). The aim of this study was to compare the efficacy and safety of a 50 mg/2 h rt-PA regimen with a 100 mg/2 h rt-PA regimen in patients with acute PTE.MethodsA prospective, randomized, multicenter trial was conducted in which 118 patients with acute PTE and either hemodynamic instability or massive pulmonary artery obstruction were randomly assigned to receive a treatment regiment of either rt-PA at 50 mg/2 h (n = 65) or 100 mg/2 h (n = 53). The efficacy was determined by observing the improvements of right ventricular dysfunctions (RVDs) on echocardiograms, lung perfusion defects on ventilation perfusion lung scans, and pulmonary artery obstructions on CT angiograms. The adverse events, including death, bleeding, and PTE recurrence, were also evaluated.ResultsProgressive improvements in RVDs, lung perfusion defects, and pulmonary artery obstructions were found to be similarly significant in both treatment groups. This is true for patients with either hemodynamic instability or massive pulmonary artery obstruction. Three (6%) patients in the rt-PA 100 mg/2 h group and one (2%) in the rt-PA 50 mg/2 h group died as the result of either PTE or bleeding. Importantly, the 50 mg/2 h rt-PA regimen resulted in less bleeding tendency than the 100 mg/2 h regimen (3% vs 10%), especially in patients with a body weight < 65 kg (14.8% vs 41.2%, P = .049). No fatal recurrent PTE was found in either group.ConclusionsCompared with the 100 mg/2 h regimen, the 50 mg/2 h rt-PA regimen exhibits similar efficacy and perhaps better safety in patients with acute PTE. These findings support the notion that optimizing rt-PA dosing is worthwhile when treating patients with PTE.Trial registrationclinicaltrials.gov; Identifier: NCT00781378

Comparing different thrombolytic dosing regimens for treatment of acute pulmonary embolism

Background Optimal dosing of recombinant tissue-type plasminogen activator (rt-PA) is important in treating pulmonary thromboembolism (PTE). Methods Objective The aim of this study was to compare the efficacy and safety of a 50 mg/2 h rt-PA regimen with a 100 mg/2 h rt-PA regimen in patients with acute PTE. Design A prospective, randomized, open label trial. Setting A multicenter trial in China. Subjects 118 patients with acute PTE and either hemodynamic instability or massive pulmonary artery obstruction. Intervention Patients were randomly assigned to receive a treatment regimen of either rt-PA at 50 mg/2 h (n = 65) or 100 mg/2 h (n = 53). Outcomes The efficacy was determined by observing the improvements of right ventricular dysfunctions (RVDs) on echocardiograms, lung perfusion defects on ventilation perfusion lung scans, and pulmonary artery obstructions on CT angiograms. The adverse events, including death, bleeding, and PTE recurrence, was also evaluated. Results Progressive improvements in RVDs, lung perfusion defects, and pulmonary artery obstructions were found to be similar in both treatment groups. This is true for patients with either hemodynamic instability or massive pulmonary artery obstruction. Three (6%) patients in the rt-PA 100 mg/2 h group and one (2%) in the rt-PA 50 mg/2 h group died as the result of either PTE or bleeding. Importantly, the 50 mg/2 h rt-PA regimen resulted in less bleeding tendency than the 100 mg/2 h regimen (3% vs. 10%), especially in patients with a body weight, 65 kg (14.8% vs. 41.2%, P = 0.049). No fatal recurrent PTE was found in either group. Conclusions Compared with the 100 mg/2 h regimen, the 50 mg/2 h rt-PA regimen exhibits similar efficacy and perhaps better safety in patients with acute PTE. These findings support the notion that optimizing rt-PA dosing is worthwhile when treating patients with PTE.

Temporary inferior vena cava filter for deep vein thrombosis and acute pulmonary thromboembolism: effectiveness and indication

Although the temporary inferior vena cava filter (IVC-F) is being used increasingly for protection against pulmonary thromboembolism (PTE), indications for its use are not established. Our strategy for the prevention of PTE is: (1) contraindication or failure of anticoagulation: permanent IVC-F; (2) for patients with residual proximal deep vein thrombosis (a) who have permanent risk factor: permanent IVC-F; (b) who have transient risk factor: temporary IVC-F; (3) others: no IVC-F. Temporary IVC-F was also implanted in deep vein thrombosis (DVT) patients without PTE who were preoperation or had floating thrombus. We investigated the outcome of patients given a temporary IVC-F versus those given a permanent IVC-F to clarify the efficacy and our strategy for implantation of a temporary IVC-F. Subjects were 12 men and 38 women with acute PTE and/or floating DVT admitted to our hospital between April 1999 and April 2002. Patient age was 25-91 years (mean 63 years). Eighteen patients were given a permanent IVC-F (group A) and 32 patients were given a temporary IVC-F (group B) as primary treatment, according to our criteria. There were no major complications in either group. Mortality after implantation of the IVC-F was 35% (6/17) in group A and 16% (4/25) in group B, with no significant difference (P = 0.14). Pulmonary thromboembolism recurred in 18% (3/17) of group A patients but in no group B patients (P = 0.10). All recurrences resulted in death. The 14 patients in group B who were not given a permanent IVC-F after removal of the temporary IVC-F survived. The temporary IVC-F can be used safely in patients with venous thromboembolism and is efficacious in preventing recurrence of PTE. Prognosis after removal of the temporary IVC-F is excellent.

Prognosis of economy class syndrome treated in intensive care unit.

The aim of this study was to clarify the prognosis of economy class syndrome (pulmonary thromboembolism following long distance flight) patients discharged from the intensive care unit. Medications, daily activities, recurrence of pulmonary thromboembolism, and quality of life were investigated for an average of 471 days following discharge from the intensive care unit. The information from the patients was obtained by means of a mailed questionnaire or telephone interview. Ten patients with economy class syndrome were enrolled in this study. Nine were female and one was male (61+/-9 years). In addition to appropriate acute care, additional management was given including the placement of an inferior vena cava filter in 3 patients and a course of oral anticoagulation therapy in 7 patients. None of them died or had recurrence of pulmonary thromboembolism. Four patients took subsequent air flights. No thromboembolic episodes were seen during the follow-up period. The long-term prognosis in these patients can be favorable with appropriate management of the acute episode in conjunction with adequate preventive measures.

妊娠中に発症した重症肺血栓塞栓症の２例

Severe pulmonary thromboembolism (PE) during pregnancy occurred in 2 young patients. One patient died from PE recurrence without placement of an inferior vena cava (IVC) filter, but the other survived with emergent filter placement before cesarean section. A 31-year-old woman presented with sudden dyspnea at 34 weeks of pregnancy. On examination, she was cyanotic and echocardiography revealed marked right heart dilatation and pulmonary hypertension. An emergent cesarean section was performed, but soon after the delivery, she fell into circulatory arrest. PE recurrence was suggested as cause, and t-PA was administered into the pulmonary artery. She was resuscitated but she died from another PE recurrence 4 days later. A 25-year-old woman, 35 weeks pregnant was admitted because of threatened abortion. She felt sudden dyspnea 3 days after admission and was diagnosed with severe PE by echocardiography and pulmonary catheterization. A Vena-Tech IVC filter™ was inserted at the suprarenal position to prevent PE relapse. Emergent cesarean section was then carried out uneventfully. Heparin and urokinase were administered postoperatively, and her pulmonary arterial pressure decreased. She was extubated 7 days later, and is now doing well 10 months later. Once severe PE has occurred, its relapse may be lethal. The IVC filter is effective in preventing recurrence. Even if the patient is young, emergent IVC filter placement to avoid fatal PE relapse is essential.