Systemic Thrombolytic Therapy Research Articles

Prevention of perioperative ischemic stroke after non-cardiac and non-neurosurgical operations in the light of the Scientific Statement and Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack AHA/ASA 2021. Part 2: Perioperative antithrombotic therapy, diagnosis, treatment

One of the possible measures that can enhance the quality of medical care, reduce the number of adverse outcomes, and also achieve target values for the use of reperfusion methods of treatment for acute ischemic stroke is to improve the system of care for patients with in-hospital ischemic stroke. One type of in-hospital stroke is perioperative stroke that develops during or 30 days after surgery. Since the publication in 2014 of the last fundamental work on the prevention of perioperative stroke, the approaches to primary and secondary prevention, diagnosis, conservative and reperfusion treatment of ischemic stroke have been seriously modified. The numerous changes have created the preconditions for a revision of existing approaches to providing care for patients with perioperative ischemic stroke. In 2021, updated documents from foreign researchers/associations on the perioperative ischemic stroke in non-cardiac and non-neurosurgical patients were published. The second part of our review presents current data on the perioperative antithrombotic prophylaxis, clinical and instrumental diagnosis, treatment and organization of care for perioperative ischemic stroke in this category of patients. The issues of using reperfusion treatment methods in non-cardiac and non-neurosurgical patients with perioperative stroke, such as systemic thrombolytic therapy and endovascular interventions, are discussed in detail, including the world experience of their “offlabel” use.

Systemic Thrombolysis of Acute Portal Venous System Thrombosis in Patients with Liver Cirrhosis: A Pilot Study

Background The prevalence of Portal Vein Thrombosis (PVT) is highly variable at different stages of liver disease: in compensated patients 10%, in decompensated patients 17%, in acute decompensated cirrhosis 9%, and in post-liver transplantation patients 2-26%. Aim The aim of the study was to assess the efficacy and safety of systemic thrombolysis in acute portal vein thrombosis in patients with liver cirrhosis. Methods A total of 10 compensated cirrhotic patients with acute portal vein thrombosis were examined by abdominal ultrasonography with color Doppler and Contrast-enhanced computerized tomography. Continuous intravenous infusion of recombinant tissue plasminogen activator(r-tPA.) and Low molecular weight heparin (LMWH) was used to treat all patients for a maximum of 7 days. Patients were followed up for improvement of clinical symptoms and radiological by abdominal ultrasound with color Doppler and contrast-enhanced computerized tomography. Results The regimen of therapy was found to be well-tolerated by all the patients. At the end of the seven days, six patients (60%) had full recanalization of the portal vein, while three had partial recanalization (30%) and no recanalization in only one patient (10%). Conclusion The preliminary data indicate that systemic thrombolytic therapy combined with low molecular weight heparin for the treatment of PVT appears to be safe and effective over a few days with no clinically significant side effects.

Pulmonary artery thrombosis. Clinical cases

Accumulating evidence supports the need to consider pulmonary artery thrombosis the separate thrombotic complication, which requires its own treatment algorithms.
 The aim of the work is to demonstrate the pulmonary artery thrombosis clinical aspects and the effect of the standard thrombotic prophylactic algorithms with clinical examples.
 Clinical cases of patients with pulmonary artery thrombosis are presented. Pulmonary artery thrombosis is considered to be the thrombotic obstruction of the pulmonary artery branches in the absence of venous and cardiac chambers thrombosis.
 Patient S. with COVID-19 and 75% of lung involvement was treated in the accordance with the actual COVID-19 treatment recommendations. Enoxaparin sodium 6000 IE once a day followed by the increasing dosage of 8000 IE twice a day was used. To prevent exacerbation tocilizumab was infused, and systemic thrombolytic therapy was performed. On the 6th day after systemic thrombolytic therapy patient died. Examination revealed thrombi in the pulmonary artery branches.
 Patient P. with continued growth of cerebral left frontoparietal region glioblastoma was hospitalized. Surgical tumor removal was performed a year ago. Conservative therapy, dexamethasone injections and anticoagulant prophylaxis (enoxaparin sodium 4000 IE once a day) were prescribed. After the patient death thrombi were found in the pulmonary artery segmental branches.
 Outpatient D. had a history of four episodes of dyspnea during the acute respiratory diseases. Computed tomography performed at the time of the third and fourth episodes revealed thrombi in the pulmonary artery segmental branches. The fourth episode occured despite anticoagulant prophylaxis with rivaroxaban (10 mg once a day). Patient was recommended to switch to low molecular weight heparins in case of any disease. There have been no recurrent episodes over the past 8 months.
 Distinctive features of pulmonary artery thrombosis pathogenesis determine the development of the complication despite anticoagulant prophylaxis. Preventive effect of anti-inflammatory drugs on the pulmonary artery thrombosis development has not been demonstrated.

Practical use of idarucizumab

The number of patients with indications for direct oral anticoagulants (DOACs) to prevent thrombotic events is steadily growing. However, in 1,1-2,2% of cases, ischemic strokes occur within DOAC therapy. In this case, DOAC use is a limitation for systemic thrombolysis, except for available reversal of anticoagulation. In order to immediately inactivate the anticoagulant effect of dabigatran etexilate (DE), reversal agent idarucizumab is used.Aim. To evaluate the effectiveness and safety of idarucizumab in clinical practice.Material and methods. The study included 9 patients taking DE who developed urgent conditions that required emergency reversal of anticoagulation with idarucizumab.Results. Normalization of thrombin time (TT) was achieved in 7 (77,8%) patients immediately after idarucizumab administration. In two patients, 10 minutes after the administration of a specific DE reversal agent, TT decreased, but did not reach reference values (case 1: TT decreased from 181 to 23,3 seconds; case 2: TT decreased from 181 to 18,3 seconds); 30 minutes after the idarucizumab administration, TT normalization was achieved.Conclusion. Nobody developed clinically significant arterial and/or venous thrombotic events during the entire period of hospitalization. Rapid reversal of anticoagulation with idarucizumab allows immediate systemic thrombolytic therapy or surgery in patients taking DE without the increase of bleeding or thrombosis risk and the need for control coagulation analysis.

Case report of repeat thrombolytic therapy in patient with acute circular-apical myocardial infarction, complicated anginous status

Presented clinical case report illustrates nonstandart approach use repeat thrombolytic therapy patient 49 y.o. with acute circular – apical myocardial infarction, after noneffective primary systemic thrombolytic therapy rtPA. Moreover, repeat thrombolytic therapy in hospital stage was vital alternative in case with significant tamely delay mechanical reperfusion. After 90 minutes then introduction rtPA has been done, we got negative dynamic on ECG in the form of additional ST-segment elevation at other (early intact) lead, and reccurent anginous pain refractory to standard doses narcotic analgesic. In connection with remote PCI – center, we supposed significant tamely deIlay to mechanical reperfusion. In view of this factors, high risk to undesired event, refractory anginous pain, we made decision of repeat thrombolytic therapy with non-immunogenic staphilokinase, and it has been effective. At a later time the disease is taking it’s normal course.

Abstract 12155: Trends in the Clinical Outcomes and Resource Utilization of Catheter-Based Thrombolytic Therapy vs. Systemic Thrombolytic Therapy in Patients With Acute Pulmonary Embolism

Introduction: Contemporary trends in clinical outcomes and resource utilization in patients with acute pulmonary embolism (PE) undergoing thrombolytic therapy are not well-known. Research Question: We wanted to analyze the trends in outcomes of catheter-based thrombolytic therapy (CDT) vs. systemic thrombolytic therapy (ST) in patients with PE. Aim: We aimed to compare the trends in in-hospital mortality, length of stay (LOS), and hospital costs in patients with PE who underwent CDT vs. ST. Methods: Using the National Inpatient Sample, all adult patients hospitalized with PE from 2012 to 2018 were identified using the International Classification of Disease diagnostic codes. Multivariate linear and logistic regression were used to obtain trends and effect sizes. Results: We identified 1.27 million patients with PE, of which 45,950 underwent thrombolytic therapy (CDT=30.1% and ST=69.9%). The mean age of patients receiving CDT vs. ST wasn't different (59.7 vs. 59.3, P=0.14). The proportion of CDT among all patients with PE increased from 0.4% in 2012 to 1.9% in 2018. Baseline characteristics of patients who underwent CDT vs. ST are shown in panel A. Risk-adjusted mortality was significantly lower in patients receiving CDT vs. ST (AOR=0.38, P=<.01). Risk-adjusted LOS was 0.19 days non-significantly higher in patients with CDT vs. ST (P-value=0.12). The hospital cost was significantly higher in patients who underwent CDT vs. ST (β=2917 USD, P<.01). Temporal trends of these outcomes are shown in panels B-D. Conclusions: It is encouraging to see an increasing trend in the utilization of CDT. In-hospital mortality decreased in patients with CDT and ST, but CDT continues to be superior. The LOS was not significantly different among these groups but significantly decreased in both groups over time. Finally, hospital cost was higher in patients with CDT vs ST, but these cost differences between CDT and ST narrowed due to decreasing cost of CDT and increasing cost of ST over time.

The Role of Mechanical Thrombectomy for Acute Massive Pulmonary Embolism in a Patient With Unilateral Lung Transplant and Atrial Septal Defect.

The risk of thromboembolic disease is high in patients with lung transplantation and is associated with significant morbidity and mortality with single healthy transplanted lung. We present a case involving successful endovascular management of life-threatening acute massive pulmonary embolism (PE) in a patient with single lung transplant and atrial septal defect (ASD). A 65-year-old man with a history of interstitial lung disease status post single left orthotopic lung transplant in 2012 presented with acute massive PE and clot burden in the pulmonary arteries of the transplanted left lung. Severe right heart dysfunction, hemodynamic instability, and requirement for vasopressors persisted post systemic thrombolytic therapy. As a result, the patient underwent successful endovascular mechanical thrombectomy with immediate improvement in oxygen saturation and hemodynamic status. The procedure was performed without adverse outcomes or paradoxical embolization despite the presence of ASD. The right heart dysfunction resolved, the patient was extubated the next day, and was discharged to home 2 days post procedure. Endovascular mechanical thrombectomy was safely used to treat acute massive PE in a single transplanted lung in the presence of ASD. Endovascular mechanical thrombectomy could be safely utilized to treat patients with lung transplant and acute massive or submassive pulmonary embolism. However, safely of mechanical thrombectomy should be determined in case-based scenarios and based on time interval from transplantation to when the thrombectomy is required.

Clinical implications of thrombolytic therapy for patients with acute intermediate-high risk pulmonary embolism in Tibet plateau, China

At present, clinical studies and case reports of systemic thrombolytic therapy for patients with acute pulmonary embolism in Tibet Plateau are very rare. There is little understanding of the risk factors, clinical characteristics, and thrombolytic therapy for patients with acute pulmonary embolism at intermediate-high risk in Tibet Plateau. In this paper, we reported the data of 4 patients with acute intermediate-high risk pulmonary embolism treated with thrombolytic therapy in Lhasa People's Hospital. The demographic characteristics, clinical manifestations, treatment, and outcomes were analyzed. We summarized the clinical features and raised scientific issues. We aimed to provide basic data to improve the standardized diagnosis and treatment of acute pulmonary embolism in plateau, and to point out the direction of future clinical research in this field.

Obstructive Shock Pulmonary Embolism: Catheter Directed Thrombolysis

Venous thromboembolism is one of the most frequently encountered condition for which patients need intensive care admission often. Most of the time patients presents with shock and hemodynamic instability if it is massive pulmonary embolism. Incidence of Vte is comparable to western population in India, studies conducted by Ayyapan et all say it around 20/10,000 admission. Studies showed higher mortality of around 50% in high risk (massive) and mortality of around 14% in intermediate risk (sub-massive) PE which necessitating more aggressive approach in high-risk groups. Rapid administration of systemic thrombolytic agents is indicated in massive pulmonary embolism patients who presents with hemodynamic instability but systemic thrombolytic therapy is associated with risk of major bleeding around 20% and haemorrhagic stroke of 2% to 5% . During systemic thrombolysis shunting of thrombolytic agents away from clot into the systemic circulation which makes it failed lysis sometimes along with major bleeding.

Neurological outcomes and reperfusion strategies in out-of-hospital cardiac arrest patients due to pulmonary embolism who underwent venoarterial extracorporeal membrane oxygenation: A post-hoc analysis of a multicenter retrospective cohort study

IntroductionThis study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA). MethodsThis was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO. ResultsAmong the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21–4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86–3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67–0.97, P = 0.020). ConclusionsFavorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients. Clinical trial registrationhttps://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Orolingual angioedema as a complication of systemic thrombolytic therapy with recombinant tissue plasminogen activator

Orolingual angioedema is a rare, but extremely dangerous complication of systemic thrombolytic therapy with recombinant tissue plasminogen activator, the incidence of which reaches 2.2-5.1 %. Orolingual angioedema is a life-threatening condition, as it can lead to airway obstruction and asphyxia. An analysis of a clinical case of orolingual angioedema as a complication of systemic thrombolytic therapy using a recombinant tissue plasminogen activator is presented, risk factors for its development and treatment methods are presented. Orolingual angioedema is a rare life-threatening complication of systemic thrombolytic therapy with recombinant tissue plasminogen activator. It is necessary to assess the severity of edema every 30-60 minutes after systemic thrombolytic therapy in order not to miss the moment of escalation of the process. For the treatment of orolingual angioedema, antihistamines, glucocorticosteroids and adrenaline are used, in case of progressive edema and impaired airway patency, emergency tracheal intubation is performed, followed by artificial ventilation of the lungs.

Tenecteplase: A Review of Its Pharmacology and Uses.

Tenecteplase: A Review of Its Pharmacology and Uses.

P372 PULMONARY EMBOLISM IN CARDIAC INTENSIVE CARE UNIT–REAL–WORLD EXPERIENCE OF A TERTIARY CENTER

Abstract Introduction Pulmonary thromboembolism represents a therapeutic challenge for patients admitted to cardiology intensive care units, given the variety of clinical presentations and available treatment opportunities. Methods This retrospective, single–center study recruited patients hospitalized in cardiology intensive care units with a diagnosis of pulmonary thromboembolism between April 2010 and May 2022. For each hospitalized patient, Wells and PESI scores were calculated, the location of the PE was identified, and acute PE resolution at discharge was determined. Patients with cardiac arrest (CCA) and/or cardiogenic shock were identified, and RV longitudinal systolic function (TAPSE) and pulmonary arterial systolic pressure (PASP) were studied. Patients were then stratified based on their clinical risk of in–hospital or 30–day mortality (early mortality); acute phase and discharge treatments and patients who developed major bleeding complications were identified. Results A total of 148 patients were recruited, with a median age of 66 years and predominantly male (51.4%). In 6.4% of patients, in–hospital death occurred (from 0% in low–risk patients to 25% in high–risk patients), 12.2% developed cardiogenic shock and/or CCA. 25.0% of patients had an ongoing neoplasm. Systemic thrombolytic therapy and Sonos were the most effective in terms of mortality (p=0.015) and RV function at discharge in high–risk patients, although associated with a high risk of bleeding. Intermediate–low–risk patients treated with reperfusion therapy showed better RV function parameters, although the sample size did not allow for statistical significance. Conclusions The results obtained are in line with those of the literature with regard to epidemiology, total hospital stay, correlation between acute PE and neoplasms, in–hospital death and FU death. Furthermore, Sonos represents an effective alternative to full–dose systemic thrombolysis in high–risk patients who cannot undergo the latter. Finally, in intermediate–low risk patients, there may be a role for reperfusion therapy in selected patients with very low bleeding risk.

Clinical experience with idarucizumab in patients with atrial fi brillation taking dabigatran etexilate

Dabigatran etexilate (DE) is a direct thrombin inhibitor that has been shown to be eff ective and safe in preventing thrombotic events in a number of studies. Currently idarucizumab, which is a monoclonal antibody and a DE antagonist, is used to immediately inactivate the DE-induced eff ect.Objective. Еvaluation of the effi ciency and safety of idarucizumab in patients receiving DE.Material and methods. 6 patients (2 men, 4 women) aged 61 to 86 years (mean age 72.8 ± 10.6 years) receiving DE, who are expected to use idarucizumab in achieving the goal of sTLT or surgery.Results. In none of the patients the use of idarucizumab was accompanied by a decrease in thrombin time of less than 11 seconds which could indicate a hypercoagulable phenomenon. Before inactivation of dabigatran etexilate thrombin time was signifi cantly higher (p < 0.05) than after the administration of the drug. There were no statistically signifi cant diff erences in the concentration of D-dimer before and after the administration of idarucizumab which indicates the absence of procoagulant properties of this drug. None of the patients developed clinically signifi cant arterial and/ or venous thrombotic events such as recurrent IS, myocardial infarction, deep vein thrombosis of the lower extremities and pulmonary embolism, during the entire period of hospitalization.Conclusion. The use of idarucizumab is allowed for systemic thrombolytic therapy and emergency surgical treatment in patients taking DE. Idarucizumab quickly and safely neutralizes the anticoagulant eff ect of DE and doesn’t have a prothrombotic activity.

High Comorbidity in Premature Infant: Abdominal Aortic Thrombosis, Wolff-Parkinson-White Syndrome, Secondary Hypothyroidism

Background. Neonatal thromboses, both venous and arterial, are a rare pathology, and experience in systemic thrombolysis is very low. Thus, the methods of adult management are currently being adapted to pediatric practice.Clinical case description. This report describes clinical case of abdominal aortic thrombosis in a premature infant with later diagnosed Wolff-ParkinsonWhite syndrome and acquired hypothyroidism developed due to antiarrhythmic therapy.Conclusion. The premature boy had high comorbidity that required many specialists’ involvement. Timely systemic thrombolytic therapy and antiarrhythmic drugs selection made it possible to save the child's life and most likely to avoid disability in the future.

The results of systemic thrombolytic therapy for acute ischemic stroke in women and men depending on the stroke risk factors

Background: Systemic thrombolytic therapy (STLT) with alteplase is the method of choice in all patients with acute ischemic stroke (IS) within the first 4.5 hours after the symptom onset. There is a noticeable difference between men and women in the clinical characteristics and results of stroke treatment; however, results of studies have been contradictory.
 Aim: To evaluate the efficacy of STLT with alteplase in women compared to men, depending on the presence of some risk factors for stroke.
 Materials and methods: This open-label prospective observational non-interventional cohort study of STLT in IS included 209 patients (102 women, the main group, and 107 men, or the comparison group) aged 32 to 86 years. All patients received STLT with alteplase within 4.5 hours from the onset of IS symptoms. The primary endpoint of the study was 28-day survival, and the secondary endpoint was the achievement of mobility independence (0 to 2 points by the modified Rankin Scale (mRS)).
 Results: The demographic and clinical patient characteristics of both groups were comparable, but women were on average 5 years older than men (p = 0.003). The index IS was not the first one in 31.4% of women and 23.4% of men (p 0.05). There were no significant differences in the severity of stroke and the timing of STLT. Men had a high mortality rate in the acute period of IS, but the difference was non-significant. PST-STLT hemorrhagic transformation was more common in men, with the difference being non-significant (2 0.743, p = 0.389). Women were more likely to have type 2 diabetes mellitus (DM2) (37.3% and 20.6%, respectively, 2 7.111, p = 0.008). In women, there was a trend towards better symptom regression by about 1 point (p = 0.129). The women with DM2 had a 13% higher survival than men (p = 0.038). The numbers of patients achieving independence (02 points on the mRS scale) by Day 28 was not different (56 women and 52 men). No between-groups differences were found in the numbers of patients with arterial hypertension and atrial fibrillation. Only 13 women (12.75%) and 21 men (20%) had a normal body mass index, while 56.3% of women and 46.7% of men had obesity 2 or 3 grades, with the gender differences being non-significant.
 Conclusion: In women, who have received STLT in the acute period of IS, the death rates and the functional outcomes were non-inferior to those in men, despite their older age, hyperglycemia in the acute period and past history of DM2. The risk factors for stroke in women, compared to men, could be the potential cause of more frequent IS recurrence (every third case in women and every fourth in men was recurrent). Despite a number of negative factors (age, obesity, metabolic syndrome, hyperglycemia, DM2, atrial fibrillation), there was a trend towards better outcomes of STLT in women.

Impact of COVID-19 on Patients Hospitalized with ST-Segment Elevation Myocardial Infarction in the United States during the Early Pandemic: An Analysis of Outcomes, Care Delivery, and Racial Disparities in Mortality.

The COVID-19 pandemic has impacted healthcare delivery to patients with ST-segment elevation myocardial infarction (STEMI). The aim of our retrospective study was to determine the effect of COVID-19 on inpatient STEMI outcomes and to investigate changes in cardiac care delivery during 2020. We utilized the National Inpatient Sample database to examine inpatient mortality and cardiac procedures among STEMI patients with and without COVID-19. In our study, STEMI patients with COVID-19 had higher inpatient mortality (47.4% vs. 11.2%, aOR: 3.8, 95% CI: 3.2−4.6, p < 0.001), increased length of stay (9.0 days vs. 4.3 days, p < 0.001) and higher cost of hospitalization (USD 172,518 vs. USD 131,841, p = 0.004) when compared to STEMI patients without COVID-19. STEMI patients with COVID-19 also received significantly less invasive cardiac procedures (coronary angiograms: 30.4% vs. 50.8%, p < 0.001; PCI: 32.9% vs. 70.1%, p < 0.001; CABG: 0.9% vs. 4.1%, p < 0.001) and were more likely to receive systemic thrombolytic therapy (4.2% vs. 1.1%, p < 0.001) when compared to STEMI patients without COVID-19. Our findings are the result of complications of SARS-CoV2 infection as well as alterations in healthcare delivery due to the burden of the COVID-19 pandemic.

A Rare Case of Acute Lower Limb Ischemia following Bee Sting

Bee sting entails allergic reaction that can be severe, sometimes even lethal as seen in our case report. These reactions can occur immediately after being stung. We report a case with arterial occlusion and severe ischemia in the lower limb a few hours after multiple bee stings. A 67-year-old male, a known case of hypertension and diabetes mellitus since 15 years and recently diagnosed with hypothyroidism, presented to the emergency department with multiple bee stings all over the body. Hence, he had developed bilateral lower limb edema with blackening of the left foot, which was gradually progressive in nature. Pedal pulsation were not palpable. After emergency treatment patient was subjected to Computed Tomography Angiography, suggestive of bilateral thrombotic occlusion of distal third of anterior tibial artery, posterior tibial artery and dorsalis pedis artery .patient was treated with systemic thrombolytic therapy and Anticoagulation.

ClotTriever system for mechanical thrombectomy of deep vein thrombosis.

There is increasing evidence that early and comprehensive removal of thrombus in deep vein thrombosis is associated with improved outcomes, including decreased incidence of post-thrombotic syndrome and debilitating long-term symptoms. Catheter-directed thrombolysis is effective for the rapid removal of clot, but it is associated with high bleeding risk. Percutaneous mechanical thrombectomy is a highly effective method for the removal of clot without the use of systemic or catheter-directed thrombolytic therapy. The Inari ClotTriever system (Inari Medical Inc., CA, USA) is a thrombectomy device, which is approved for deep vein thrombosis by the US FDA in 2017. Herein we review the current treatment strategies using the ClotTriever system, its specifications, indications and current state of literature.

Successful percutaneous catheter-directed treatment of high-risk pulmonary embolism: a case report

Pulmonary embolism (PE) is an acute cardiovascular syndrome characterized by high incidence and mortality. The therapy of this condition is based on anticoagulation and hemodynamic support, but in case of high-risk mortality, the European Society of Cardiology (ESC) guidelines recommend systemic thrombolytic therapy and surgical embolectomy if thrombolysis is contraindicated or has failed; nowadays several percutaneous catheter-directed treatments for local thrombolysis or mechanical embolectomy are available, but they have IIa class of recommendation, because of lack of robust scientific evidence favoring their use. We described a case of high-risk PE treated with a novel percutaneous system for mechanical embolectomy, which consists of a large aspiration catheter that was advanced in the pulmonary artery, capturing and removing a vast thrombus, of 15 centimeters in length. This therapeutic strategy avoided the risk of hemorrhagic complications related to systemic thrombolysis, exiting in the achievement of fast patient hemodynamic stabilization and symptoms resolution, without complications. Computed tomography (CT) pulmonary angiography after 10 days from the intervention revealed the complete resolution of pulmonary artery filling defects, and the patient was discharged asymptomatic. Percutaneous catheter-directed treatments represent an effective alternative therapy for PE, but further studies are needed to demonstrate safety and superiority over the actually recommended therapy.