Thrombolysis For Acute Pulmonary Embolism Research Articles

Efficacy and safety of catheter-based thrombectomy versus catheter-directed thrombolysis in acute pulmonary embolism.

Data comparing catheter-based thrombectomy (CBT) and catheter-directed thrombolysis (CDT) in acute pulmonary embolism are lacking. To address this, we performed a meta-analysis of prospective and retrospective studies of CBT and compared it to performance goal rates of mortality and major bleeding from a recently published network meta-analysis. When compared with performance goal for CDT based on historical studies, CBT was noninferior for all-cause mortality (6.0% vs 6.87%; P-valueNI < .001), non-inferior and superior for major bleeding (4.9% vs 11%; P-valueNI < .001 and P < .001 for superiority).

Ultrasound-Facilitated, Catheter-Directed Thrombolysis for Acute Pulmonary Embolism.

Acute pulmonary embolism (APE) poses a significant risk to patient health, with treatment options varying in efficacy and safety. Ultrasound-facilitated catheter-directed thrombolysis (USCDT) has emerged as a potential alternative to conventional catheter-directed thrombolysis (CDT) for patients with intermediate to high-risk APE. This study aimed to compare the efficacy and safety of USCDT versus conventional CDT in patients with intermediate to high-risk APE. This observational retrospective study was conducted at the Armed Forces Hospital, Al-Hada, Taif, the Kingdom of Saudi Arabia (KSA), on 135 patients diagnosed with APE and treated with either USCDT or CDT (58 underwent CDT, while 77 underwent USCDT). The primary efficacy outcome was the change in the right ventricle to the left ventricle (RV/LV) diameter ratio.Secondary outcomes included changes in pulmonary artery systolic pressure and the Miller angiographic obstruction index score. Safety outcomes focused on major bleeding events. Both USCDT and CDT significantly reduced RV/LV diameter ratio (from 1.35 ± 0.14 to 1.05 ± 0.17, P < 0.001) and systolic pulmonary artery pressure (SPAP) (from 55 ± 7 mmHg to 38 ± 7 mmHg, P < 0.001) at 48- and 12-hours post-procedure, respectively, with no significant differences between treatments. However, USCDT was associated with a significantly lower rate of major bleeding events compared to CDT (0% vs. 3.4%, P = 0.008). Multivariate logistic regression analysis revealed that USCDT was associated with a 71.9% risk reduction of bleeding (OR = 0.281, 95% CI = 0.126 - 0.627, P = 0.002). USCDT is a safe and effective alternative to CDT for the treatment of intermediate to high-risk APE, as it significantly reduces the risk of major bleeding.

Comparison of In-Hospital Outcomes between Early and Late Catheter-Directed Thrombolysis in Acute Pulmonary Embolism: A Retrospective Observational Study.

The purpose of this study is to evaluate whether early initiation of catheter-directed thrombolysis (CDT) in patients presenting with acute pulmonary embolism is associated with improved in-hospital outcomes. A retrospective cohort was extracted from the 2016-2019 National Inpatient Sample database, consisting of 21,730 weighted admissions undergoing CDT acute PE. From the time of admission, the sample was divided into early (<48 h) and late interventions (>48 h). Outcomes were measured using regression analysis and propensity score matching. No significant differences in mortality, cardiac arrest, cardiogenic shock, or intracranial hemorrhage (p > 0.05) were found between the early and late CDT groups. Late CDT patients had a higher likelihood of receiving systemic thrombolysis (3.21 [2.18-4.74], p < 0.01), blood transfusion (1.84 [1.41-2.40], p < 0.01), intubation (1.33 [1.05-1.70], p = 0.02), discharge disposition to care facilities (1.32 [1.14-1.53], p < 0.01). and having acute kidney injury (1.42 [1.25-1.61], p < 0.01). Predictors of late intervention were older age, female sex, non-white ethnicity, non-teaching hospital admission, hospitals with higher bed sizes, and weekend admission (p < 0.01). This study represents a comprehensive evaluation of outcomes associated with the time interval for initiating CDT, revealing reduced morbidity with early intervention. Additionally, it identifies predictors associated with delayed CDT initiation. The broader ramifications of these findings, particularly in relation to hospital resource utilization and health disparities, warrant further exploration.

Effectiveness and safety of catheter-directed thrombolysis for acute pulmonary embolism: a systematic review and meta-analysis

Abstract Background Catheter-directed thrombolysis (CDT) can accelerate relief of the right ventricle overload secondary to acute pulmonary embolism (PE). The effectiveness and safety of CDT, also in relation to dose, duration, and different devices, are still a matter of debate. Purpose We conducted a systematic review and meta-analysis to assess effectiveness and safety of CDT for intermediate- and high-risk acute PE. Methods We systematically searched PubMed, Web of Science and CENTRAL (inception-December 2022) and selected randomized controlled trials (RCTs), observational studies, and epidemiological analysis (DRG-based, nationwide studies), focusing on standard CDT (sCDT) vs. ultrasound-assisted catheter-directed thrombolysis (USAT) for intermediate- and high-risk acute PE, according to European Society of Cardiology definition. We obtained pooled estimate rates for bleeding (intracranial and major), in-hospital/30-day fatality rate, and estimated the early improvement of several hemodynamic parameters (i.e. right/left ventricle [RV/LV] ratio, pulmonary artery pressure [PAP]) and long-term course. Results Overall, 58 studies with 37,496 patients (mean age 60 years) were included. The pooled intracranial bleeding rate was 0.15% (95%CI: 0-0.58%) in trials and cohort studies, and 0.87% (95%CI: 0.44-1.42%) in epidemiological studies; Fig. 1. Randomized trials comparing CDT vs. anticoagulation alone reported neither intracranial nor fatal bleeding events. In trials and cohort studies, higher rates of major bleedings were observed with longer (4.5%; 95%CI: 2.4-7.1%) vs. shorter (0.7%, 95%CI: 0-2.2%) treatment duration (p=0.01), irrespective of the dose; Fig. 2. Longer CDT regimens were associated with a high fatality rate of 2.8% (95%CI: 1.5-4.2%) vs. 0.1% (95%CI: 0-1.1%) with shorter CDT treatment (&amp;lt;0.01), disregarding the lytic dose; Fig. 2. All early hemodynamic and radiological outcomes assessed in available studies improve after CDT regardless of dose, duration, and type of device. However, data on the long-term course of PE after CDT has been rarely reported in literature. Conclusions The available evidence supports the notion that CDT strategies may represent a safe option for reversing right ventricular dysfunction due to acute PE. Overall, the reported rate of intracranial bleeding was below 1%. Patients exposed to longer CDT regimens had a higher incidence of major bleeding and fatality. Randomised trials with clinical outcomes are necessary to truly establish optimal patient selection and CDT protocol.Prevalence of intracranial bleedingOutcomes in RCTs and cohort studies

Efficacy and Safety of Anticoagulation, Catheter-Directed Thrombolysis, or Systemic Thrombolysis in Acute Pulmonary Embolism

BackgroundThe optimal treatment strategy of patients with pulmonary embolism (PE) (especially those with intermediate risk) continues to evolve and remains controversial. ObjectivesThis study sought to compare the efficacy and safety of anticoagulation (AC) alone, catheter-directed thrombolysis (CDT), and systemic thrombolysis (ST) in patients with acute PE. MethodsPubMed and EMBASE were searched for randomized controlled trials or observational studies which compared outcomes of AC alone, CDT, and ST in acute PE. Efficacy outcome was all-cause mortality. Safety outcomes were major bleeding and intracranial hemorrhage (ICH). ResultsWe identified 45 studies (17 randomized controlled trials, 2 prospective nonrandomized trials, and 26 retrospective observational trials), which included 81,705 patients. When compared with AC alone, CDT had lower mortality (OR: 0.55; 95% CI: 0.39-0.80) but higher major bleeding (OR: 1.84; 95% CI: 1.10-3.08) and numerically higher ICH (OR: 1.51; 95% CI: 0.75-3.04). ST was associated with no difference in mortality but higher major bleeding (OR: 2.16; 95% CI: 1.38-3.38) and ICH (OR: 2.26; 95% CI: 1.14-4.48) when compared with AC alone. The risk of mortality (OR: 2.05; 95% CI: 1.46-2.89) and ICH (OR: 1.50; 95% CI: 1.13-1.99) was higher with ST when compared with CDT. Findings were similar when analysis was restricted to trials of intermediate risk PE. ConclusionsIn patients with acute PE, when compared with AC alone, CDT was associated with a lower mortality but higher risk of bleeding. Moreover, CDT had an enhanced safety profile when compared with ST.

Randomized Controlled Trial of Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: The PEERLESS Study Design and Rationale

Randomized Controlled Trial of Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: The PEERLESS Study Design and Rationale

Fixed-dose ultrasound-accelerated thrombolysis for acute pulmonary embolism: short- and long-term outcome data from a single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Background Data on clinical outcomes after fixed-dosed ultrasound-accelerated thrombolysis (USAT) for acute pulmonary embolism (PE) is still limited, particularly concerning safety and long-term course. Methods We studied patients with acute PE treated with USAT at a University Hospital between 2018 and 2022. Patients were candidates to USAT if acute PE fulfilled the criteria of high-risk or intermediate-high risk (plus additional markers of clinical severity or early deterioration) as per European guidelines. USAT was given at a standard regimen of 10 mg alteplase/catheter over 15 hours. Early outcomes included: mean pulmonary arterial pressure (mPAP) before and after treatment, National Early Warning Score (NEWS) during USAT; 30-day all-cause death, 30-day hemodynamic decompensation, 30-day PE recurrence, and 30-day major bleeding complications (ISTH definition). Late outcomes were: confirmed CTEPH, persistent post-PE dyspnea, and "post-PE impairment" (PPEI), as defined by the combination of dyspnea with sPAP&amp;gt;35 mm Hg, TAPSE &amp;lt;1.6cm, or RV/RA gradient &amp;gt;36 mmHg, death. Results We included 161 patients: the mean age was 67.8 (SD 14.6) years and 96 were men. All had acute bilateral PE and were treated with two catheters for a median alteplase dose of 20 mg. All patients received anti-Xa activity-adjusted unfractionated heparin, except one, who received argatroban. mPAP decreased from a mean of 35.6 (SD 9.8) to 25.6 (SD 8.2) mmHg after a 15-hour course of treatment (absolute difference 10.2 mmHg; SD 8.1). The NEWS decreased from a median of 5 (Q1-Q3: 4-6) points before USAT to 3 (Q1-Q3: 2-4) points after USAT. No hemodynamic decompensations were recorded within 30 days of hospitalization. One (0.6%) recurrence of PE within 30 days occurred. Two major bleeding (1.2%), of which one (0.6%) was intracranial and fatal, were observed. No other deaths were recorded within 30 days of acute PE. Of 125 patients followed at our center and included in the long-term analysis (median follow-up time 104, Q1-Q3 91-200, days), CTEPH was diagnosed in 2 (1.6%) patients. In one patient, CTEPH was most probably pre-existing, namely present already at the time of "acute" PE, based on hemodynamic and radiological findings. CTEPH was incident in the other patient. 24 (19.2%) patients reported persistent dyspnea, of whom 5 (4.0%) fulfilled the PPEI criteria. Death was recorded in 8 (6.4%) patients after a median of 591 (Q1-Q3; 517-710) days and no event was PE-related. One (0.8%) recurrent PE occurred. Conclusions USAT rapidly reduced the mean pulmonary arterial pressure in selected intermediate-high and high-risk acute PE with a good safety profile. Only 4.0% patients had residual symptoms and right ventricular dysfunction over long-term follow-up. This data reassures USAT being an effective and safe option for acute PE also in terms of long-term outcomes.

Clinical outcomes of ultrasound-assisted coagulation monitoring-adjusted catheter-directed thrombolysis for acute pulmonary embolism

BackgroundUltrasound-assisted catheter-directed thrombolysis (USAT) may reverse right ventricular dysfunction due to acute pulmonary embolism (PE) with a favorable safety profile. MethodsWe studied intermediate-high- and high-risk acute PE patients who underwent USAT at the University Hospital Zurich, 2018–2022. The USAT regimen included alteplase 10 mg per catheter over 15 h, therapeutic-dosed heparin, and dosage adaptations based on routinely monitored coagulation parameters, notably anti-factor Xa activity and fibrinogen. We focused on the mean pulmonary arterial pressure (mPAP) and the National Early Warning Score (NEWS) before and after USAT, and reported the incidence of hemodynamic decompensation, PE recurrence, major bleeding, and death over 30 days. ResultsWe included 161 patients: 96 (59.6 %) were men and the mean age was 67.8 (SD 14.6) years. Mean PAP decreased from a mean of 35.6 (SD 9.8) to 25.6 (SD 8.2) mmHg, whereas the NEWS decreased from a median of 5 (Q1-Q3 4–6) to 3 (Q1-Q3 2–4) points. No cases of hemodynamic decompensation occurred. One (0.6 %) patient had an episode of recurrent PE. Two (1.2 %) major bleeding events occurred, including one (0.6 %) intracranial, fatal hemorrhage in a patient with high-risk PE, severe heparin overdosing, and a recent head trauma (with negative CT scan of the brain performed at baseline). No other deaths occurred. ConclusionsUSAT resulted in a rapid improvement of hemodynamic parameters among patients with intermediate-high risk acute PE and selected ones with high-risk acute PE, without any recorded deaths related to PE itself. A strategy including USAT, therapeutic-dosed heparin, and routinely monitored coagulation parameters may partly explain the overall very low rate of major bleeding.

CRT-300.10 Randomized Controlled Trial of Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: The PEERLESS Study Design and Rationale

CRT-300.10 Randomized Controlled Trial of Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: The PEERLESS Study Design and Rationale

Abstract 9981: Comparison of 30-day Readmission and Healthcare Costs Between Early and Late Catheter Directed Thrombolysis for Acute Pulmonary Embolism in the United States

Introduction: Pulmonary embolism (PE) is a major cause of morbidity and mortality accounting for 100,000 deaths per year in the United States and 5-10% of in-hospital deaths. There is sparse comparative data on readmission patterns and healthcare costs in patients who undergo early versus late catheter directed thrombolysis (CDT) for acute PE. Hypothesis: Procedure Day for acute PE may be associated with difference in 30-day readmission rates and healthcare costs. Methods: This study was performed by using National readmission database between January 2016 and November 2019. Patients with acute PE who underwent CDT were identified using the International Classification of Diseases, Tenth Edition (ICD 10) codes. Patients who were &lt;18 years old and patients who underwent thrombolysis for STEMI and Ischemic stroke were excluded. Results: Among a total of 23,564 patients who underwent CDT for acute pulmonary embolism, 12,528 (53.2%) were male and 11034 (46.8%) were female (P=0.014). The mean age of the patients was 60.3 years. The median length of hospital stay was 4 days. Thirty-day readmission rates were higher for patients who underwent CDT on Day 2 or afterwards compared to Day 1 and Day 0 (7.1% vs 5.7% vs 5.2%, for day 2, day 1 and day 0 respectively; p=0.016). Patients who had CDT on Day 2 or more had a higher rate of 30-day readmission mortality compared to those who had CDT on Day 1 or 0 (0.6% vs 0.3% vs 0.2%, for day 2, day 1 and day 0 respectively; Adjusted OR 2.96, 95% CI 1.18 to 7.47 (Ref: day 0), p = 0.021). Thirty-day readmission for heart failure was higher among patients who had CDT on Day 2 vs those who had CDT on Day 0 of admission (2% vs 1.0% vs 0.9%, for day 2, day 1 and day 0 respectively; Adjusted OR 1.97, 95% CI 1.24 to 3.13 (Ref: day 0), p=0.004). Total 30-day costs for patients who underwent CDT on day 2 or more was higher in patients with CDT on day 2 ($55,087; IQR $41,361-$74,092) compared to those with CDT on Day 1 ($45,942; IQR $36,016-$61,211) or Day 0 ($44,814; IQR $34,264-$60,072) (P &lt;0.001). Conclusions: Delayed CDT for acute PE was associated with increased rates of 30-day readmission, readmission mortality, readmission for heart failure and increased healthcare costs. These findings emphasize the need for earlier CDT for the treatment of acute PE.

Fixed-Dose Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Pulmonary Embolism Associated with COVID-19.

Background. Fixed-dose ultrasound-assisted catheter-directed thrombolysis (USAT) rapidly improves hemodynamic parameters and reverses right ventricular dysfunction caused by acute pulmonary embolism (PE). The effectiveness of USAT for acute PE associated with coronavirus disease 2019 (COVID-19) is unknown. Methods and results. The study population of this cohort study consisted of 36 patients with an intermediate-high- or high-risk acute PE treated with a fixed low-dose USAT protocol (r-tPA 10–20 mg/15 h). Of these, 9 patients tested positive for COVID-19 and were age–sex-matched to 27 patients without COVID-19. The USAT protocol included, beyond the infusion of recombinant tissue plasminogen activator, anti-Xa-activity-adjusted unfractionated heparin therapy (target 0.3–0.7 U/mL). The study outcomes were the invasively measured mean pulmonary arterial pressure (mPAP) before and at completion of USAT, and the National Early Warning Score (NEWS), according to which more points indicate more severe hemodynamic impairment. Twenty-four (66.7%) patients were men; the mean age was 67 ± 14 years. Mean ± standard deviation mPAP decreased from 32.3 ± 8.3 to 22.4 ± 7.0 mmHg among COVID-19 patients and from 35.4 ± 9.7 to 24.6 ± 7.0 mmHg among unexposed, with no difference in the relative improvement between groups (p = 0.84). Within 12 h of USAT start, the median NEWS decreased from six (Q1–Q3: 4–8) to three (Q1–Q3: 2–4) points among COVID-19 patients and from four (Q1–Q3: 2–6) to two (Q1–Q3: 2–3) points among unexposed (p = 0.29). One COVID-19 patient died due to COVID-19-related complications 14 days after acute PE. No major bleeding events occurred. Conclusions. Among patients with COVID-19-associated acute PE, mPAP rapidly decreased during USAT with a concomitant progressive improvement of the NEWS. The magnitude of mPAP reduction was similar in patients with and without COVID-19.

Contemporary practice patterns and outcomes of systemic thrombolysis in acute pulmonary embolism

ObjectiveAlthough systemic thrombolysis (ST) is the standard of care in the treatment of high-risk pulmonary embolism (PE), large variations in real-world usage exist, including its use to treat intermediate-risk PE. A paucity of data is available to define the outcomes and practice patterns of the ST dose, duration, and treatment of presumed and imaging-confirmed PE. MethodsWe performed a multicenter retrospective study to evaluate the real-world practice patterns of ST use in the setting of acute PE (presumed vs imaging-confirmed intermediate- and high-risk PE). Patients who had received tissue plasminogen activator for PE between 2017 and 2019 were included. We compared the baseline clinical characteristics, tissue plasminogen activator practice patterns, and outcomes for patients with confirmed vs presumed PE. ResultsA total of 104 patients had received ST for PE: 52 with confirmed PE and 52 with presumed PE. Significantly more patients who had been treated for presumed PE had experienced cardiac arrest (n = 47; 90%) compared with those with confirmed PE (n = 23; 44%; P < .01). Survival to hospital discharge was 65% for the patients with confirmed PE vs 6% for those with presumed PE (P < .01). The use of ST was contraindicated for 56% of the patients with confirmed PE, with major bleeding in 26% but no intracranial hemorrhage. ConclusionsThe in-hospital mortality of patients with confirmed acute PE has remained high (35%) in contemporary practice for those treated with ST. A large proportion of these patients had had contraindications to ST, and the rates of major bleeding were significant. Those with confirmed PE had had a higher survival rate compared with those with presumed PE, including those with cardiac arrest. This observation suggests a limited role for empiric thrombolysis in cardiac arrest situations.

Fixed-Dose Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Pulmonary Embolism Associated with COVID-19

Fixed-Dose Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Pulmonary Embolism Associated with COVID-19

Catheter-based therapies in acute and chronic pulmonary embolism

The aim of this study is to summarize currently available catheter-based therapies in acute and chronic pulmonary embolic disease. Catheter-based therapies to treat acute pulmonary embolism and its sequelae such as chronic thromboembolic pulmonary hypertension (CTEPH) are emerging as the next frontier within interventional cardiology. However, the true benefit of these catheter-based therapies in intermediate-risk and high-risk pulmonary embolism and CTEPH remains unclear. The current evidence supporting such interventions comes primarily from small single-arm studies in acute pulmonary embolism and case series in CTEPH. Appropriately powered randomized controlled trials with meaningful clinical outcomes as endpoints are needed to elucidate the true benefit of catheter-based therapies in pulmonary embolism compared with other treatment modalities such as anticoagulation and systemic thrombolysis in acute pulmonary embolism and riociguat and pulmonary endarterectomy in CTEPH.

Intrapulmonary Artery Thrombolysis in Acute Pulmonary Embolism: Case Series from King Chulalongkorn Memorial Hospital Experience

Acute pulmonary embolism (PE) is a life-threatening condition. In patient who has contraindication for systemic thrombolysis and inappropriate for surgical embolectomy, there is a role of catheter interventions. However, the data are limited. The aim of the present report was to assess a role of intrapulmonary artery thrombolysis bolus in acute PE. A retrospective review of the use of intrapulmonary artery thrombolysis in acute PE. The data were collected from 14 patients with massive or submassive PE who had contraindication or inappropriate for systemic thrombolysis and unsuitable for surgical embolectomy. After intrapulmonary thrombolysis was given, patients were followed clinically and hemodynamically until discharged and after 1 month. Pulmonary pressure was collected at pre and post intervention. Of the 14 patients (age 59±19 years, 78.6% female), 86% were diagnosed as submassive PE. Mean dose of tissue plasminogen activator (rt-PA) was 28±14 mg given as bolus and continuous infusion (19±10 hours). One patient died after completion of intrapulmonary infusion rt-PA at day 90, which did not relate to PE and the treatment. After intervention, mean PA pressure was significantly reduced from 32.3±6.0 to 21.0±4.3 mmHg (p&lt;0.001). Three patients (21%) had minor bleeding (hematoma at access site). The present case series showed that intrapulmonary infusion of rt-PA was effective and safe in patient with massive and submassive PE who had contraindication or inappropriate to systemic thrombolysis or inoperable surgical thrombectomy. Keywords: Acute pulmonary embolism; Intrapulmonary thrombolysis; Tissue plasminogen activator; Surgical thrombectomy

Temporal Analysis of Tachycardia During Catheter Directed Thrombolysis for Acute Pulmonary Embolism.

To evaluate the effect of catheter directed thrombolysis (CDT) on heart rate (HR) in patients with sinus tachycardia and acute pulmonary embolism (PE). A retrospective chart review was performed for patients who underwent CDT with tPA for acute massive or submassive PE between 12/2009 and 2/2020. Included were patients who presented with tachycardia at the time of initiation of CDT. Patients with chronic PE, atrial fibrillation, beta blocker therapy, adjunctive endovascular therapy, systemic thrombolysis, or who expired before conclusion of CDT were excluded. HR was measured approximately every hour during CDT. Graphs were plotted of HR as a function of CDT duration. Two interventional radiologists identified the point of plateau (POP) on the graph where CDT had maximized its benefit in decreasing the patient's HR. Discrepancies were adjudicated by a third interventional radiologist and the median of the 3 measurements was selected. The primary endpoint was the duration of CDT from initiation until the POP. 48 patients were included (52.5 ± 14.7 years, 56.3% female). The POP occurred after 13.1 ± 6.1 hours, by which point HR had been reduced from 110 ± 9.2 bpm to 88 ± 10.6 bpm. Sinus tachycardia was not resolved in 10 patients even though they achieved maximal improvement in HR after 11.3 ± 6.7 hours. Patients presenting with sinus tachycardia related to acute PE achieved maximal, sustained reduction in heart rate from CDT, after approximately 13 hours of infusion. Patients who did not resolve their tachycardia by that point in time were unlikely to resolve it by the conclusion of CDT.

Thrombolysis in Acute Pulmonary Embolism: Are we overdoing it?

Aim and Methods:We aimed to study the clinical data and outcome of patients admitted in our center with acute pulmonary embolism (PE) over a 5-year period from May 2013 to April 2018. The main outcome data included were: in - hospital bleeding, in - hospital right ventricular (RV) function improvement, pulmonary arterial hypertension improvement, duration of hospital stay, and 30- and 90-day mortality.Results:A total of 114 (69 m, 55 f) patients with the mean age of 55 ± 15 years were included. Patients who had involvement of central pulmonary trunk called as “Central PE” group (n = 82) and others as “Peripheral PE” group (n = 32). There were more women in the peripheral PE group (53.1% vs. 34.1%, P = 0.05), while RBBB (22% vs. 3.1%, P = 0.02) and RV dysfunction (59.8% vs. 25%, P = 0.002) were noted more in the central PE group. Systemic thrombolysis was done in 53 patients (49 central, 4 peripheral), of which only 3 had hypotension and 28 patients were in the Intermediate-high risk group. The overall inhospital, 30-day, and 90-day mortalities were 3.6, 13.2, and 22.8%, respectively. Bleeding was significantly higher in the thrombolysis group compared to the nonthrombolysis group (18.9% vs. 0, P = 0.0003). However, improvement in pulmonary hypertension was noted more in thrombolysis group compared to nonthrombolytic group (49% vs. 21.2%, P = 0.01).Conclusion:This retrospective data from a tertiary center in South India showed that short- and mid-term mortality of patients with PE still remains high. The high nonguideline use of thrombolysis has been reflected in the increased bleeding noted in our study.

Short Duration Catheter-directed Thrombolysis for Acute Pulmonary Embolism Rapidly Improves Acute Cardiac Function

Treatment of massive and submassive pulmonary embolism (PE) has been shown to be a valuable therapeutic modality. However, a paucity of data exists, regarding length and guidelines for treatment and typically these patients are treated by other than vascular surgery specialists. The aim of this study is to evaluate the effectiveness and safety of short duration treatment of massive and submassive PE, exclusively by vascular surgeons, without routine follow-up pulmonary angiography. Retrospective analysis of prospectively collected data at a single-institution treating massive and submassive PE with catheter-directed thrombolysis (CDT). Internal review board approval was obtained. Descriptive statistical analysis was performed from the data set. Continuous covariates were presented in mean (SD) or median (IQR) and categorical covariates as number (percentage). For continuous variables, a paired t test was used to measure results against the baseline. P value less than 0.05 was defined as statistically significant. STATA® statistical software was used for analysis. From January of 2013 to December of 2016, 28 consecutive patients were treated for massive and submassive PE with CDT. All patients had evidence of right heart strain on echocardiogram, as evidence by a right ventricular to left ventricular (RV/LV) diameter ratio of >0.9. Of the 28 patients, 19 (68%) had hemodynamic derangement with either systolic blood pressure (SBP) less then 90 or tachycardia (HR>100). The mean RV/LV ratio before CDT was 1.18. After therapy, RV/LV ratio was reduced to 0.86 at 48hr (P<0.0001). In addition, mean right ventricular systolic pressure (RVSP) before CDT treatment was 53mm Hg, and after treatment, RVSP was reduced to 40mm Hg at 48-hr (P value=0.0001). There was complete resolution of hypotension in hemodynamically unstable patients (i.e., SBP <90) after CDT. Mean HR before therapy was 102. After 24hr of CDT, mean HR reduced to 84 (P<0.0001). From 2013 to 2016, there was a significant decrease in mean hospital length of stay from 8days to 4days (P=0.05). Mean t-PA dose used decreased, as well, from 2014 (21.7mg) to 2016 (14.9mg), but this was not statistically significant (P=0.13). There was no major bleeding complications or CDT-related death in any of the patients treated during the study period. CDT treatment of massive and submassive PE is safe and highly efficacious at reducing right heart strain acutely. Significant hemodynamic improvement was shown in our cohort throughout the study period. Improvement in tachycardia and resolution of hypotension were seen within 24hr of CDT. Tissue plasminogen activator dosage decreased throughout the study period as a more restrictive approach to follow-up angiography was used without adverse safety or patient outcomes.

Large-Bore Aspiration Thrombectomy versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: A Propensity Score–Matched Comparison

PurposeTo compare effectiveness and safety of large-bore aspiration thrombectomy (LBAT) with catheter-directed thrombolysis (CDT) for treatment of acute massive and submassive pulmonary embolism (PE). Materials and MethodsThis retrospective review included patients with acute PE treated with LBAT or CDT using tissue plasminogen activator (tPA) between December 2009 and May 2020. A propensity score based on Pulmonary Embolism Severity Index class and PE severity (massive vs submassive) was calculated, and 26 LBAT cases (age 60.2 y ± 17.1, 14/26 women) were matched with 26 CDT cases (age 59.7 y ± 14.2, 14/26 women). ResultsThe CDT group had 22.1 mg ± 8.1 tPA infused over 21.2 h ± 6.6. Both groups demonstrated similar initial and final systolic pulmonary artery pressure (PAP) (LBAT: 54.5 mm Hg ± 12.9 vs CDT: 54.5 mm Hg ± 16.3, P = .8, and LBAT: 42.5 mm Hg ± 14.1 vs CDT: 42.6 mm Hg ± 12.1, P = .8, respectively) and similar reductions in heart rate (LBAT: −5.4 beats/min ± 19.2 vs CDT: −9.6 beats/min ± 15.8, P = .4). CDT demonstrated a higher reduction in Miller score (−10.1 ± 3.9 vs −7.5 ± 3.8, P = .02). LBAT resulted in 1 minor hemorrhagic complication and 2 procedure-related mortalities, and CDT resulted in 1 minor and 1 major hemorrhagic complication. ConclusionsLBAT and CDT resulted in similar reductions of PAP and heart rate when used to treat acute PE. CDT reduced thrombus burden to a greater degree. Although hemorrhagic complications rates were not significantly different, the LBAT group demonstrated a higher rate of procedure-related mortality. Larger studies are needed to compare the safety of these techniques.

Evaluation of Fibrinogen Levels during Catheter-Directed Thrombolysis for Acute Pulmonary Embolism

PurposeTo evaluate the effect of catheter-directed thrombolysis (CDT) with tissue plasminogen activator (tPA) on plasma fibrinogen levels (PFLs) in the setting of acute pulmonary embolism (PE) and the relationship between PFL and hemorrhagic complications. Materials and MethodsA retrospective review of CDT procedures between 2009 and 2019 identified 147 CDT procedures for massive or submassive PE (55.8% males; age, 56.5 ± 14.8 years; 90.5% submassive). All patients received therapeutic anticoagulation during CDT with unfractionated heparin (UFH) (69.4%) or low-molecular-weight heparin (LMWH, 30.6%) infusion. CDT was performed with ultrasound-accelerated thrombolysis (USAT) catheters (n = 98), conventional catheter-directed thrombolysis (CCDT) catheters (n = 34), or a combination of both (n = 15). ResultsThere was a decrease (P = .007) of 15.1 ± 69.4 mg/dl from the initial PFL (376.1 ± 122.7 mg/dl) to the final PFL (361 ± 118.7 mg/dl), which was measured after a mean of 24.1 ± 11.7 hours with a mean tPA dose of 28.3 ± 14.2 mg. The fibrinogen nadir was 327.6 ± 107.1 mg/dl measured 13.4 ± 10.3 hours after initiation of thrombolysis. Of patients with hemorrhagic complications (n = 6), initial, final, and nadir PFL were not significantly lower (P = .053, P = .081, and P = .086, respectively) than the remainder of the cohort. No significant difference was noted in initial and final PFL between the LMWH and UFH groups (P = .2 and P = .1, respectively) or between the CCDT and USAT groups (P = .5 and P = .9, respectively). The UFH group had a lower nadir PFL than the LMWH group (P = .03). ConclusionsDespite a significant drop in PFL during CDT for acute PE, this was not associated with hemorrhagic complications. These findings were not affected by the choice of anticoagulant or catheter delivery system.