Thrombolysis For Massive Pulmonary Embolism Research Articles

Successful cardiopulmonary resuscitation combined with thrombolysis for massive pulmonary embolism during peri-cardiac arrest.

Successful cardiopulmonary resuscitation combined with thrombolysis for massive pulmonary embolism during peri-cardiac arrest.

THE CONUNDRUM OF TREATING SUB-MASSIVE PULMONARY EMBOLISM IN A PREGNANT PATIENT

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary embolism (PE) is an important cause of morbidity and mortality during pregnancy. 20% of maternal deaths during pregnancy are related to PE. Treatment decisions are further complicated by pregnancy, in which the outcome of the fetus is also at stake. While emerging data support the use of thrombolytic therapy during pregnancy for life-threatening PE, there are no conclusive data on the appropriate treatment (1). CASE PRESENTATION: A 7-week pregnant, 31-year-old women with history of protein C deficiency was admitted for acute onset dyspnea and syncopal episode. On physical examination, the heart rate was 136 bpm and blood pressure was 121/87 mm Hg. Oxygen saturation was 97% on room air. There was no heart murmur, lungs were clear to auscultation, and the extremities appeared normal. Troponin I level was 0.908 ng/mL and Bnp was 115pg/ml. Electrocardiogram showed sinus tachycardia. Computed tomography pulmonary angiography showed large pulmonary emboli involving the distal main pulmonary artery, left and right pulmonary arteries extending into the proximal lobar and segmental arteries bilaterally (Image 1 and 2). Echocardiogram showed a dilated right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Multi-disciplinary team meeting was done to discuss the risks and benefits of systemic thrombolysis and catheter-directed thrombolysis. The patient chose catheter-directed thrombolysis and after the procedure, patient's symptoms improved significantly. Due to risk of fetal anomalies from radiation exposure, patient decided to terminate her pregnancy. DISCUSSION: The guidelines on management of life-threatening acute PE in pregnancy is not well established. Teratogenicity due to thrombolytic agent has not been reported, though the risk of maternal hemorrhage is high. Catheter directed thrombolysis reduces the complications encountered in systemic thrombolysis yet require radiation exposure. CTPA and catheter directed thrombolysis usually exposes patient between 50-100mGy of radiation. During the 5th-10th week of gestation, exposures between 50-100Gy have uncertain potential side effects to the fetus. Systemic review of case series and case reports among 172 pregnant females treated with thrombolytic agents, the maternal mortality was 1%, the incidence of fetal loss was 6%, and the incidence of maternal hemorrhagic complications was 8% (2). Limited data is available for catheter directed thrombolytic therapy during 1st trimester of pregnancy, and if deemed necessary, a shared decision making with patient regarding termination of pregnancy should be made (3). CONCLUSIONS: The use of systemic or catheter directed thrombolysis is associated with positive outcomes and relatively low risk of complications. Yet, clinical judgements should be made based on individual patients risks versus benefits. REFERENCE #1: Heavner MS, Zhang M, Bast CE, Parker L, Eyler RF. Thrombolysis for Massive Pulmonary Embolism in Pregnancy. Pharmacotherapy. 2017 Nov;37(11):1449-1457. doi: 10.1002/phar.2025. Epub 2017 Oct 10. REFERENCE #2: Turrentine MA, Braems G, Ramirez MM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv. 1995;50(7):534. REFERENCE #3: Bloom AI, Farkas A, Kalish Y. Pharmacomechanical catheter directed thrombolysis for pregnancy related iliofemoral deep vein thrombosis. J Vasc Interv Radiol 2015;26:992-1000. 10.1016/j.jvir.2015.03.001 DISCLOSURES: No relevant relationships by Ki Lee, source=Web Response No relevant relationships by Pratik Patel, source=Web Response No relevant relationships by SHREY SHAH, source=Web Response

Clinical outcomes of submassive pulmonary embolism thrombolysis\u2014an Indian experience

BackgroundAcute pulmonary thromboembolism is the most dangerous presentation of venous thromboembolic disease. The role of thrombolysis in massive pulmonary embolism has been studied extensively, but the same is not there for submassive pulmonary embolism. This study is aimed at evaluating the effects of thrombolysis in acute submassive pulmonary embolism. This was a prospective, case-control, observational study. Patients presenting with acute submassive pulmonary embolism were divided into thrombolysis group and control group depending on whether they received thrombolysis plus anticoagulation or anticoagulation only, respectively.ResultsA total of 86 patients were included in the study. Forty-two patients were in the thrombolysis group, and 44 patients were in the control group. The mean ± SD age in the control and thrombolysis groups was 63.3 ± 14.7 and 56.4 ± 13.8 years, respectively. The two groups were well matched in sex distribution and associated comorbidities like COPD, active surgery, major trauma, and immobilization. On echocardiography, dilated RA/RV in pre-treatment vs. post-treatment was seen in 20 (45.5%) vs. 20 (45.5%) in the control group and 26 (61.9%) vs. 11 (26.2%) in the thrombolysis group. Similarly, RV systolic dysfunction in pre-treatment vs. post-treatment was seen in 24 (54.5%) vs. 21 (47.7%) in the control group and 22 (52.4%) vs. 8 (19.0%) in the thrombolysis group. Pulmonary artery pressure in pre-treatment vs. post-treatment was 64.4 ± 15.0 vs. 45.9 ± 9.9 mmHg in the control group and 68.3 ± 17.4 vs. 31.4 ± 6.9 mmHg in the thrombolysis group. In control vs. thrombolysis group, there were 5 vs. 1 death, 6 vs. 1 hemodynamic decompensation, and 6 vs. 1 patient needing mechanical ventilation.ConclusionThrombolysis in submassive pulmonary embolism is associated with better right ventricular functions, lower pulmonary artery pressures, and comparable mortality rates.

To Thrombolyse or Not to Thrombolyse: Two Years Experience of Thrombolysis of Sub-Massive Pulmonary Embolism in a District General Hospital.

AimsCurrent British Thoracic Society (BTS) guidelines only recommend thrombolysis of pulmonary embolism (PE) in patients who are haemodynamically compromised. Newer evidence suggests a mortality benefit for the thrombolysis of sub-massive PE with right ventricular strain. We wanted to assess the outcome and safety of thrombolysis in patients with sub-massive PE in a DGH.MethodsThe notes for patients with sub-massive PE and thrombolysis from a two-year period were reviewed. Evidence of right ventricular strain and myocardial necrosis based on bedside echocardiography, computed tomography (CT) scan and troponin T were indications for thrombolysis.ResultsA total of 22 patients had thrombolysis of PE in the study period (56±14 years). Fourteen patients were classified as sub-massive PE (55±15 years). Out of eight patients who had thrombolysis of massive PE (58±14 years), three were initially classified as sub-massive PE but deteriorated within the next 48 hours and became haemodynamically unstable. In all patients, the diagnosis was confirmed with a CT pulmonary angiography (CTPA).Mean troponin was 82 in the sub-massive PE group and 102 in the massive PE group. The clinical condition and haemodynamic of patients improved rapidly within a few hours after thrombolysis.Post-thrombolysis echocardiography was performed, 17 patients had normal right ventricles with normal pulmonary arterial pressures.ConclusionThrombolysis of sub-massive pulmonary embolism is feasible in a district general hospital and seems to be a safe procedure, particularly in younger patients. It results in rapid improvement in the clinical condition of patients with a small incidence of bleeding complications.

Role of interventional radiology in the treatment of COVID-19 patients: Early experience from an epicenter

ObjectiveTo highlight the role of interventional radiology (IR) in the treatment of patients hospitalized with coronavirus disease 2019 (COVID-19). MethodsRetrospective review of hospitalized patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and had one or more IR procedures at a tertiary referral hospital in New York City during a 6-week period in April and May of 2020. ResultsOf the 724 patients admitted with COVID-19, 92 (12.7%) underwent 124 interventional radiology procedures (79.8% in IR suite, 20.2% at bedside). The median age of IR patients was 63 years (range 24–86 years); 39.1% were female; 35.9% in the intensive care unit. The most commonly performed IR procedures were central venous catheter placement (31.5%), inferior vena cava filter placement (9.7%), angiography/embolization (4.8%), gastrostomy tube placement (9.7%), image-guided biopsy (10.5%), abscess drainage (9.7%), and cholecystostomy tube placement (6.5%). Thoracentesis/chest tube placement and nephrostomy tube placement were also performed as well as catheter-directed thrombolysis of massive pulmonary embolism and thrombectomy of deep vein thrombosis. General anesthesia (10.5%), monitored anesthesia care (18.5%), moderate sedation (29.8%), or local anesthetic (41.1%) was utilized. There were 3 (2.4%) minor complications (SIR adverse event class B), 1 (0.8%) major complication (class C), and no procedure-related death. With a median follow-up of 4.3 months, 1.1% of patients remain hospitalized, 16.3% died, and 82.6% were discharged. ConclusionInterventional radiology participated in the care of hospitalized COVID-19 patients by performing a wide variety of necessary procedures.

Systemic Intravenous Thrombolysis for Massive Pulmonary Embolism after Intracranial Surgery for Traumatic Head Injury: When Absolute Becomes Relative!

AbstractIntravenous thrombolysis is the preferred treatment for massive pulmonary embolism with hemodynamic instability, when there are no contraindications to the therapy. However, when absolute contraindications to thrombolysis are present, clinicians are at a crux, especially when mechanical thrombectomy is also not possible. We present a case of a 40-year-old man with polytrauma with head injury who developed massive pulmonary embolism requiring intravenous thrombolysis on day 15 after decompressive craniotomy—possibly a first in the literature. The patient, however, successfully recovered from this near-fatal episode. With this report, we wish to highlight that at a near-dying situation, no contraindication is absolute, and all possible efforts must be made by the clinician to save the patient.

Thrombolysis for Massive Pulmonary Embolism in Pregnancy.

Pregnant women are at high risk for venous thromboembolism, including pulmonary embolism (PE), given expected changes in coagulation, fibrinolysis, and venous blood flow. In fact, PE is the leading cause of maternal death in the United States. Nonpregnant patients who develop PE with hypotension or show signs of deterioration after anticoagulation receive thrombolytics as a standard of care. Pregnant women, however, have been excluded from clinical trials with thrombolytics, and all data available in this population are published as case reports or case series. We reviewed all reports of thrombolytics, systemic or catheter directed, used in pregnant patients with massive PE. This article summarizes the risks for thromboembolism in pregnancy, compares and contrasts thrombolytic agents in this setting, and provides a recommendation for management of massive PE in this special population. Overall, reports suggest that the use of these agents is associated with beneficial outcomes and a relatively low risk of complications. The quality of this evidence is low, and clinical judgment is required to assess individual patients for risks versus benefits of thrombolysis.

Thrombolysis in Massive Pulmonary Embolism

Massive pulmonary embolism (PE) is defined as sustained hypotension, not due to the cause other than PE, pulselessness, or persistent profound bradycardia. Therefore, although PE exhibits variable clinical course, massive PE is a life-threatening condition of which in-hospital mortality reaches over 15% and which consequently requires thrombolysis as well as anticoagulation. According to recent guidelines of PE, systemic thrombolysis is recommended over no such therapy in patients with massive PE who do not have a high bleeding risk. Currently, continuous infusion of alteplase over 2 hours plus anticoagulation using unfractionated heparin constitutes a standard regimen. When systemic thrombolysis is failed or contraindicated, patients with massive PE can undergo surgical embolectomy or catheter-directed thrombolysis, if specialist services and expertise are available. In addition, hemodynamic and respiratory supports, including extracorporeal membrane oxygenation, are needed for successful treatment of massive PE. Keywords: Heparin, Hypotension, Pulmonary embolism, Tissue plasminogen activator

Случай успешного тромболизиса при массивной тромбоэмболии легочной артерии у беременной

We present a case of successful thrombolysis in massive pulmonary embolism in pregnancy. No severe haemorrhagic complications were observed. Thrombolysis was effective and did not affect the pregnancy and the fetus.

The case of a successful cardiopulmonary resuscitation with using thrombolysis in massive pulmonary embolism in puerperant after cesarean section

Pulmonary embolism (PE) is a leading cause ofmaternalmortality in the developedworld.1 Today, there are few reports of the use of thrombolytic therapy in pregnant and postpartum women.2,3 We present here the case of a puerperant with massive PE who underwent successful thrombolysis during cardiopulmonary resuscitation. In 30-year-old puerperal woman after elective caesarean sectionoccurred suddenacute dyspnea anddecreasedblood pressure. An immediate electrocardiogram showed a typical S1-Q3 pattern. After 10min from the onset of clinical signs of pulmonary embolismwas fixed cardiac arrest. Intubation andmechanical ventilation and chest compressions were started immediately. There was pulseless electrical activity. Within 1h was intravenously administered 5mg epinephrine. Thrombolysis with streptokinase (250,000units) was administered 1h after the beginning of resuscitation. Immediately after administration of streptokinase restore blood pressure but developed a severe uterine bleeding. Hysterectomy and packing was performed for to stop bleeding. Floating thrombus in the right femoral vein was subsequently diagnosed. The operation thrombectomy was performed after 2 days. On the fifth day the patient was disconnected from the ventilator. The patientwasdischarged fromthehospital after 20dayswithoutneurological complications. The rescue thrombolysis on background CPR is a very important option in the treatment of massive pulmonary embolism with cardiac arrest.

PCV17 - Effectiveness And Cost-Effectiveness Of Catheter-Directed Thrombolysis In Massive Pulmonary Embolism

PCV17 - Effectiveness And Cost-Effectiveness Of Catheter-Directed Thrombolysis In Massive Pulmonary Embolism

Percutaneous thromboaspiration and thrombolysis in massive pulmonary embolism – A series of 45 consecutive cases

Percutaneous thromboaspiration and thrombolysis in massive pulmonary embolism – A series of 45 consecutive cases

PMM.18 Thrombolysis for massive pulmonary embolism in pregnancy: A case report and literature review

Venous thromboembolism (VTE) remains to be the leading cause of maternal mortality. The management of pulmonary embolus (PE) in pregnancy is complicated by the lack of validated trials. The use...

Thrombolysis for massive pulmonary embolism in pregnancy: a case report

Mortality from pulmonary embolism (PE) in pregnancy might be related to challenges in targeting the right population for prevention. Such targeting could help ensure that the correct diagnosis is suspected and adequately investigated, and allow the initiation of the timely and best possible treatment of this disease. In the literature to date only 18 case reports of thrombolysis in pregnant women with PE have been reported, and showed beneficial effects for both mother and fetus in terms of mortality and complications with acceptable bleeding risks. We present here the case of a pregnant patient with massive PE who underwent successful thrombolysis. A 26-year-old pregnant (at 24 weeks) woman was admitted 4 h after onset of sudden acute dyspnea and chest pain. An immediate electrocardiogram showed a typical S1-Q3-T3 pattern. The echocardiogram showed a distended right ventricle with free-wall hypokinesia and displacement of the interventricular septum toward the left ventricle. Thrombolysis with recombinant tissue plasminogen activator (alteplase 10 mg bolus, then 90 mg over 2 h) was administered. Pelvic examination and ultrasound showed regular fetal heart beat, and regular placental and liquid presence. No problems developed for the mother or fetus in the subsequent days or at discharge. In conclusion, in pregnant patients with life-threatening massive PE, thrombolytic therapy can be administered, and the use of echocardiographic, laboratory, and clinical data can be useful tools to achieve a rapid diagnosis and make a therapeutic decision, but additional studies need to be performed to further define its use.

Successful Thrombolysis of Massive Pulmonary Embolism

Successful Thrombolysis of Massive Pulmonary Embolism

Thrombolysis for massive pulmonary embolism in pregnancy: a case report

Thrombolysis for massive pulmonary embolism in pregnancy: a case report

Use of bivalirudin for heparin-induced thrombocytopaenia after thrombolysis in massive pulmonary embolism: a case report

A 68-year-old man was referred to the emergency department 6 h after onset of sudden acute dyspnoea. Immediate ECG showed sinus tachycardia with the typical S1-Q3-T3 pattern and incomplete right bundle branch block. The echocardiogram showed the presence of mobile thrombus in the right atrium, a distended right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Lung spiral computed tomography (CT) showed bilateral pulmonary involvement and confirmed the picture of a thrombotic system in the right atrium and caval vein. Thrombolytic treatment with recombinant tissue plasminogen activator (rt-PA) and heparin (alteplase 10 mg bolus, then 90 mg over 2 h) was administered. Six hours after thrombolysis bleeding gums and significant reduction in platelet count (around 50,000) were observed. Heparin was discontinued and bivalirudin (0.1 mg/kg bolus and 1.75 mg/kg per h infusion) plus warfarin was initiated and continued for 5 days until the international normalised ratio (INR) was within the therapeutic range (2.0–3.0) for 2 consecutive days, with concomitant platelet count normalisation. Lung spiral and lower abdominal CT before discharge did not show the presence of clots in the pulmonary arteries of the right and left lung. This case suggests that bivalirudin could offer promise for use in patients with heparin-induced thrombocytopaenia (HIT) after thrombolysis for massive pulmonary embolism.

Massive Pulmonary Embolism: What Level of Aggression?

Massive pulmonary embolism (PE) with hemodynamic instability (e.g., hypotension and cardiac shock) is associated with a poor prognosis and high mortality rates (> 50%). Accordingly patients with massive PE should be treated aggressively with thrombolytic agents (or surgical or interventional procedures). Streptokinase, urokinase, and recombinant tissue plasminogen activator (rtPA) have been used, with generally similar results. Among patients with submassive PE [i.e., subclinical right ventricular (RV) dysfunction and normal blood pressure], the role of thrombolytic therapy is controversial. Thrombolytic therapy is generally NOT indicated in normotensive patients without RV dysfunction. In this context, some experts recommend prompt administration of thrombolytic agents to prevent cardiogenic shock but data affirming benefit over heparin alone are lacking. Thrombolytic therapy is generally NOT indicated in normotensive patients without RV dysfunction. The role of echocardiography, computed tomographic (CT) scans, and cardiac biomarkers (e.g., troponins, brain natriuretic peptide, etc.) to identify patients who might benefit from aggressive thrombolytic therapy remains controversial. This article reviews indications for thrombolysis in massive PE, with an emphasis on recent data derived from normotensive patients. Further, we propose a diagnostic and therapeutic algorithm for treating acute PE. Additional studies are required to determine the benefit and safety of thrombolytic therapy for PE.

Repeated thrombolytic therapy after initial unsuccessful thrombolysis in massive pulmonary embolism

In patients with massive pulmonary embolism threatened by haemodynamic instability, thrombolytic treatment is recommended.1 But when it fails, therapeutic options remain limited and are mainly guided by local expertise. In...

Radiologie interventionnelle thoracique

Thoracic interventional radiology includes a variety of diagnostic and therapeutic procedures that are currently used since several years in pneumology. Among diagnostic procedures, the most common are CT-guided fine-needle punctures of the thorax, in particular in peripheral lung lesions not accessible to endoscopy. There are two kinds of therapeutic procedures: the first one includes treatments obtained by direct puncture, such as drainage of lung and pleural abscesses. The second option consists in endovascular treatment of either arteriovenous fistulas, bronchial artery embolotherapy of massive haemoptysis, pulmonary artery thrombolysis of massive pulmonary embolism, vena cava filter placement, and stent placement in superior vena cava obstructions.