Thrombolysis For Pulmonary Embolism Research Articles

Underuse of reperfusion therapy with systemic thrombolysis in high-risk acute pulmonary embolism in a Portuguese center

IntroductionReperfusion therapy is generally recommended in acute high-risk pulmonary embolism (HR-PE), but several population-based studies report that it is underused. Data on epidemiology, management and outcomes of HR-PE in Portugal are scarce. ObjectiveTo determine the reperfusion rate in HR-PE patients, the reasons for non-reperfusion, and how it influences outcomes. MethodsIn this retrospective cohort study of consecutive HR-PE patients admitted to a thromboembolic disease referral center between 2008 and 2018, independent predictors for non-reperfusion were assessed by multivariate logistic regression. PE-related mortality and long-term MACE (cardiovascular mortality, PE recurrence and chronic thromboembolic disease) were calculated according to the Kaplan–Meier method. Differences stratified by reperfusion were assessed using the log-rank test. ResultsOf 1955 acute PE patients, 3.8% presented with hemodynamic instability. The overall reperfusion rate was 50%: 35 patients underwent systemic thrombolysis, one received first-line percutaneous embolectomy and one rescue endovascular treatment. Independent predictors of non-reperfusion were: age, with >75 years representing 12 times the risk of non-treatment (OR 11.9, 95% CI 2.7–52.3, p=0.001); absolute contraindication for thrombolysis (31.1%), with recent major surgery and central nervous system disease as the most common reasons (OR 16.7, 95% CI 3.2–87.0, p<0.001); and being hospitalized (OR 7.7, 95% CI 1.4–42.9, p=0.020). At a mean follow-up of 2.5±3.3 years, the survival rate was 33.8%. Although not reaching statistical significance for hospital mortality, mortality in the reperfusion group was significantly lower at 30 days, 12 months and during follow-up (relative risk reduction of death of 64% at 12 months, p=0.013). Similar results were found for MACE. ConclusionsIn this population, the recommended reperfusion therapy was performed in only 50% of patients, with advanced age and absolute contraindications to fibrinolysis being the main predictors of non-reperfusion. In this study, thrombolysis underuse was associated with a significant increase in short- and long-term mortality and events.

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.

Cost-Comparison of Mechanical Thrombectomy and Catheter-Directed Thrombolysis in Intermediate-Risk Pulmonary Embolism

BackgroundCatheter-directed thrombolysis (CDT) and large-bore mechanical thrombectomy (MT) are the leading percutaneous-based therapies for the management of intermediate-risk pulmonary embolism (PE). While previous studies have demonstrated their procedural safety and efficacy, the cost implications of these interventions remain unclear. This study aims to conduct a cost-benefit analysis to evaluate the economic advantages associated with CDT and MT from the perspective of the treating hospital. MethodsA total of 372 consecutive patients with intermediate-risk acute PE who underwent either MT or CDT at 3 academic centers between 2013 and 2021 were included in this analysis. The costs of care incurred during the index hospitalization for the 2 treatment groups were collected and compared using an adjusted cost model. ResultsThis study compared the hospital costs of 226 patients who underwent CDT and 146 patients who underwent MT. In the unadjusted overall cohort, the use of CDT was associated with a numerical but nonsignificant increase in costs amounting to $5120 relative to MT (P = .062). This cost difference was primarily driven by the longer length of stay in the intensive care unit and hospital for CDT patients, particularly earlier in the studied timeframe. However, when accounting for confounders including variations between the treating institutions and the timing of treatment during the study period, the adjusted cost differential between CDT and MT narrowed to $1351 (P = .71). ConclusionsThis multicenter cost analysis does not reveal a clear cost advantage of 1 treatment over the other for intermediate-risk PE. The observed cost differences were influenced by variations in practice patterns across the study period and among the 3 participating institutions. Future efforts should also focus on strategies to reduce the length of stay, improve efficiency, and minimize the overall cost of care for intermediate-risk PE patients.

Catheter-directed thrombolysis versus thrombectomy for submassive and massive pulmonary embolism: A systematic review and meta-analysis

IntroductionControversy surrounds the optimal therapy for submassive and massive pulmonary embolism (PE). We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus surgical and catheter-based thrombectomy in patients with submassive and massive PE. MethodsWe searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of CDT versus thrombectomy in submassive and massive PE. Studies were identified and data were extracted by two independent reviewers. A random effects model was used to calculate risk ratios (RRs) with 95 % confidence intervals (CIs). Outcomes included in-hospital mortality, procedural complications, hospital and intensive care unit (ICU) length of stay (LOS), 30-day readmissions, and right ventricle/left ventricle (RV/LV) ratio improvement. ResultsEight observational studies with 1403 patients were included, of whom 50.0 % received CDT. Compared to thrombectomy, CDT was associated with significantly lower in-hospital mortality (RR 0.62; 95 % CI 0.43–0.89; p = 0.01) and similar rates of major bleeding (p = 0.61), blood transfusion (p = 0.41), stroke (p = 0.41), and atrial fibrillation (p = 0.71). The hospital and ICU LOS, 30-day readmissions, and degree of RV/LV ratio improvement were similar between the two strategies (all p > 0.1). In subgroup analyses, in-hospital mortality was similar between CDT and catheter-based thrombectomy (p = 0.48) but lower with CDT compared with surgical thrombectomy (p = 0.01). ConclusionsIn patients with submassive and massive PE, CDT was associated with similar in-hospital mortality compared to catheter-based thrombectomy, but lower in-hospital mortality compared to surgical thrombectomy. Procedural complications, LOS, 30-day readmissions, and RV/LV ratio improvement were similar between CDT and any thrombectomy. Randomized controlled trials are indicated to confirm our findings.

OC 01.3 Systemic and Catheter-Directed Thrombolysis in High and Intermediate-High Risk Pulmonary Embolism: A Systematic Review with Meta-Analysis

OC 01.3 Systemic and Catheter-Directed Thrombolysis in High and Intermediate-High Risk Pulmonary Embolism: A Systematic Review with Meta-Analysis

Paradoxical pulmonary artery systolic pressure response with catheter-directed therapies for pulmonary embolism

BackgroundEarly data on use of catheter-directed therapies (CDT) for treatment of Intermediate or High-Risk pulmonary embolism (PE) show improvement in pulmonary artery systolic pressures (PAsP) and RV/LV ratios. Occasionally a paradoxical rise in PAsP was observed with CDT utilizing ultrasound-assisted thrombolysis (USAT). It is unclear whether this pattern is seen with CDT utilizing mechanical aspiration. ObjectivesTo investigate and compare the changes in PAsP between those who underwent CDT with USAT to those with mechanical aspiration. MethodsA retrospective analysis of those diagnosed with Intermediate or High-Risk PE who underwent CDT using USAT or mechanical aspiration from 7/2013 to 3/2023. The primary outcome was comparison of PAsP changes between the two modalities. Secondary outcomes include length of stay, mortality, and bleeding complications. ResultsA total of 142 patients were analyzed, of which 93 underwent USAT and 49 underwent mechanical thrombectomy. The mechanical thrombectomy group had significantly lower post-intervention PAsP than the USAT group (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (−16.5 ± 2.7 vs. −7.7 ± 3.2 mmHg. p < 0.0001). A higher frequency of a paradoxical rise in PAsP was observed in the USAT group (22 % vs 4.1 %, p < 0.001). ConclusionsCDT utilizing mechanical thrombectomy was associated with lower post-interventional PAsP and greater mean negative change compared to USAT. Occasional paradoxical rises in PAsP were observed with both types of CDT, but they were more frequent with USAT. Hemodynamic monitoring should be considered after CDT. Condensed unstructured abstractWe report a retrospective comparison of changes to pulmonary artery systolic pressures (PAsPs) between catheter-directed ultrasound-assisted thrombolysis (USAT) and catheter-directed mechanical thrombectomy in Intermediate and High-Risk pulmonary embolism. Those treated with mechanical thrombectomy compared to USAT had significantly lower post-interventional PAsP (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (−16.2 ± 2.7 vs. −7.5 ± 3.2 mmHg, p < 0.0001). A paradoxical rise in PAsP was observed more frequently in the USAT group than the mechanical thrombectomy group (22 % vs 4.1 %, p < 0.001).

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

Catheter-directed Pulmonary Artery Embolism Thrombolysis: A Life-saving Procedure for Postpartum Pulmonary Embolism: A Near-miss Case

Catheter-directed Pulmonary Artery Embolism Thrombolysis: A Life-saving Procedure for Postpartum Pulmonary Embolism: A Near-miss Case

Qualitative assessment of available online patient resources for pulmonary embolism and deep vein thrombosis.

This study seeks to evaluate the quality and readability of freely available online patient information resources for deep vein thrombosis (DVT) and pulmonary embolism (PE). Internet searches were performed for five DVT and PE search terms in July 2020 across three search engines and two metasearch engines. Qualitative content analysis was performed. Readability was assessed using four validated instruments. Two hundred fifty websites were identified of which 62 websites met inclusion criteria.Website structure and content were satisfactory (>50% overall score), accountability was mixed between DVT (47%) and PE (56%) sites, while interactivity was poor (<30%). On qualitative content analysis, anticoagulation (95.2%) was the most discussed treatment while the most discussed procedures were IVC filter placement for DVT and thrombolysis for PE. Overall readability was difficult with median level suitable for ages 14-18years. Freely available online DVT and PE patient information resources publish appropriate content but have very variable accountability and poor readability for the average patient.

Predictors of chronic thromboembolic pulmonary hypertension in patients with submassive pulmonary embolism treated with catheter-directed thrombolysis versus anticoagulation alone: A secondary analysis of the SUNSET sPE trial

ObjectiveChronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is a morbid complication with suboptimal treatment. We aimed to evaluate the biomarker profile and functional outcomes in patients with submassive PE (sPE) treated with catheter-directed thrombolysis (CDT) compared with anticoagulation alone (ACA). We performed a secondary biomarker and survey analysis of the SUNSET sPE (standard vs ultrasound-assisted catheter thrombolysis for submassive pulmonary embolism) randomized trial comparing standard CDT to ultrasound-assisted thrombolysis in patients with sPE. MethodsAs a part of the SUNSET sPE study, patients who did not receive an intervention were enrolled in the medical (ACA) arm. The biomarkers associated with CTEPH in the literature (ie, CCL2, CXCL10, PTX3, GDF-15, RAGE, BCA-1, TFPI) were collected and measured using a multiplex assay at diagnosis, discharge, and 3-month follow-up. Patients underwent a 6-minute walk test and answered quality-of-life questionnaires (pulmonary embolism quality of life; University of California, San Diego, shortness of breath questionnaire; 36-item short-form survey) at 3 months after diagnosis. Comparisons were made using the Student t test. Nonparametric tests were used when the distributions were not normal. Significance was set at P ≤ .05. ResultsA total of 72 patients (age, 56 ± 15 years; 40.3% women) were included in the present analysis. Of these 72 patients, 53 underwent CDT and 19 were included in the ACA arm. The baseline right ventricle/left ventricle ratios were similar between the two groups (CST, 1.8; ACA, 1.7). The survival and complication rates were similar between the two groups. At discharge, CXCL10 (768.9 ± 148.6 pg/mL vs 3032.0 ± 1201.0 pg/mL; P = .018) and PTX3 (3203.5 ± 1298.0 pg/mL vs 12,716.2 ± 6961.5 pg/mL; P = .029) were lower in the CDT group and displayed a quicker return to baseline than in the ACA group. This trend, although not significant, was also seen with the other biomarkers. At 3 months, the 6-minute walking distance and quality-of-life scores were similar between both groups. ConclusionsIn patients with sPE, the biomarkers of CTEPH were lower with CDT compared with ACA. At 3 months, both groups demonstrated similar biomarker levels, 6-minute walking distances, and quality-of-life scores.

Tenecteplase: A Review of Its Pharmacology and Uses.

Tenecteplase: A Review of Its Pharmacology and Uses.

Comparison of the Clinical Efficacy and Safety of Standard and Ultrasound-Assisted Thrombolysis for Pulmonary Embolism: A Systematic Review and Meta-Analysis.

Catheter-directed therapy has been increasingly used in acute pulmonary embolism (PE). Whether ultrasound-assisted thrombolysis (USAT) is superior to standard catheter-directed thrombolysis (SCDT) remains unclear. This is a systemic review and meta-analysis of comparative trials on USAT and SCDT for PE to determine whether either modality yielded better clinical efficacy and safety. Major databases including PubMed, Embase, Cochrane Central, and Web of Science were searched through March 16, 2023. Studies that reported outcomes of SCDT and USAT for acute PE were included. Studies reported data on therapeutic efficacy (a reduction in the right ventricle [RV]/left ventricle [LV] ratio, a reduction in the systolic pulmonary artery pressure [mm Hg], change in Miller index, length of intensive care unit [ICU] and hospital stay) and safety outcomes (in-hospital mortality, overall and major bleeding events). A total of 9 studies with 2610 patients were included in the meta-analysis. The analysis showed significantly greater improvement in the RV/LV ratio in the SCDT group than in the USAT group (mean difference [MD]: -0.155; 95% confidence interval [CI]: -0.249 to -0.006). No statistically significant differences were found between groups comparing change in systolic pulmonary artery pressure (MD: 0.592 mm Hg; 95% CI: -2.623 to 3.807), change in Miller index (MD: -4.1%; 95% CI: -9.5 to 1.3%), hospital stay (MD: 0.372 days; 95% CI: -0.972 to 1.717), and ICU stay (MD: -0.073.038 days; 95% CI: -1.184 to 1). No significant difference was noted in safety outcomes, including in-hospital mortality (pooled odds ratio: 0.984; 95% CI: 0.597 to 1.622), and major bleeding (pooled odds ratio: 1.162; 95% CI: 0.714 to 1.894). In our meta-analysis of observational and randomized studies, USAT is not superior to SCDT in patients with acute PE.INSPLAY registration number: INPLASY202240082. This study compared SCDT and USAT in patients with acute pulmonary embolism. We found no additional benefit in PA pressure change, thrombus reduction, hospital stay, mortality and major bleeding rate. Additional study using consistent treatment protocol is necessary for further investigation.

Hospital length of stay in patients with cancer who undergo systemic or ultrasound-catheter-directed thrombolysis for pulmonary embolism.

e22521 Background: Pulmonary Embolism is a common cause of morbidity and mortality in patients with cancer. Current treatment can be done depending on severity with Catheter-Directed Thrombolysis (CDT), which can have addition of ultrasound to it (EKOS brand US-CDT), or Systemic Thrombolysis (ST). There is limited data regarding its use and different outcomes in population with cancer. We conducted a retrospective cohort study to identify characteristics and hospital length of stay, in patients with PE who underwent either treatment, comparing patients with and without cancer. Methods: This retrospective cohort study identified 1,270 patients across several facilities diagnosed with Pulmonary Embolism with and without cancer. Patients who had pregnancy, stroke, and bleeding were excluded, with a final sample of 1007 patients. Patients were stratified into two groups based on the treatment they received, a group who underwent Ultrasound-Catheter-Directed Thrombolysis (US-CDT) with EKOS brand (575 patients 57.1%), and a group who received Systemic Thrombolysis (ST) (432 patients 42.9%). Patients subsequently were divided in patients who had cancer (n = 66) and those who did not have cancer (n = 941). We assessed patient’s characteristics such as hypertension (HTN), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD) and events during hospitalization. The primary outcome was hospital length of stay with either treatment and compare it in patients with and without cancer. Negative binomial regression was used to determine the association and prediction for length of stay according to different characteristics. Results: Of the 1007 patients with PE who received either Ultrasound-Catheter-Directed or Systemic Thrombolysis, the mean age was 58.65 years, 45.78% were female and 54.22% were male. The mean length of stay (LOS) was 7.41 days. The maximum length of stay was 143 days. There was no relationship between the type of treatment used for the PE and the length of stay. Patients with cancer compared to patients without cancer are more likely with an incidence rate ratio (IRR) of 1.479 (P &lt; 0.0001, CI 1.228~ 1.78) to have an extended length of stay. Conclusions: Patients with cancer have more risks of complications from cancer and thrombosis. In the case of thrombosis associated with cancer, especially pulmonary embolism, there is limited data regarding different treatment options for it for this population. Although there was no difference in LOS with either US-CDT and ST, our study is the first one to identify that patients with cancer and PE who are more likely to have extended length of stay (IRR = 1.479 P &lt; 0.0001, CI 1.228~ 1.78) regardless of treatment with ST or US-CDT. However, the limitation is having a relatively small sample size, and other possible confounders from the patients and the disease itself. Further research is required to investigate this.

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.

A clinical case of successful thrombolysis in pulmonary embolism during pregnancy

The risk of venous thromboembolic complications among pregnant women and puerperas is higher than in the general population, which is due to traditional risk factors, as well as physiological and anatomical changes that occur during pregnancy. Symptoms and signs of venous thromboembolic complications during pregnancy are often nonspecific and may coincide with the consequences of changes, including dyspnea, limb edema, and tachycardia. D-dimer levels may be elevated during ongoing pregnancy, limiting its use as a laboratory marker. Identification of the source of thromboembolism in the veins of the lower extremities can be difficult due to the proximal localization of thrombosis in pregnant women, the rare detection of thrombi in this area is associated with incompressibility of the veins due to their intrapelvic location, as well as with altered blood flow mechanics. The main method of treatment is the use of low molecular weight heparins, however, in case of massive thromboembolism, leading to hemodynamic instability and a high risk of mortality, thrombolytic therapy is indicated. Thrombolytic therapy is associated with an increased risk of hemorrhagic complications. The use of warfarin and direct oral anticoagulants during pregnancy is contraindicated due to the possibility of penetration of drugs through the placental barrier. The article presents a clinical case of successful thrombolysis in a patient with pulmonary embolism in late pregnancy. The chosen tactics of management corresponded to the clinical guidelines and made it possible to successfully treat pulmonary embolism without complications for the mother and fetus. Drugs were used that do not penetrate the placental barrier and do not have teratogenic effects.

Mortality and bleeding associated with the management of sub-massive pulmonary embolism: a systematic review and Bayesian network meta-analysis

Current guidelines recommend anticoagulation (AC) for low and intermediate-risk pulmonary embolism (PE) and systemic thrombolysis (tPA) for high risk (massive) PE. How these treatment options compare with other modalities of treatment such as catheter directed thrombolysis (CDT), ultrasound assisted catheter thrombolysis (USAT), and administering lower dose of thrombolytics (LDT) is unclear. There is no study that has compared all these treatment options. We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials in patients with submassive (intermediate risk) PE. Fourteen randomized controlled trials were included, comprising 2132 patients. On Bayesian network meta-analysis, a significant decrease in mortality was noted in tPA versus AC. There was no significant difference between USAT versus CDT. For risk of major bleeding, there was no significant difference in relative risk of major bleeding between tPA versus AC and USAT versus CDT. tPA was found to have a significantly higher risk of minor bleeding and a lower risk of recurrent PE compared to AC. Systemic thrombolysis is associated with a significant reduction in mortality and recurrent PE compared to anticoagulation but an increased risk of minor bleeding. There was no difference in risk of major bleeding. Our study also shows that while the newer modalities of treatment for pulmonary embolism are promising, there is lack of data to comment on the purported advantages.

C-34 | Impact of Timing of Catheter-Directed Thrombolysis in Pulmonary Embolism on In-Hospital Outcomes

Catheter-Directed Thrombolysis (CDT) has emerged as an acceptable and safe modality in the treatment of intermediate to high-risk pulmonary embolism (PE). It is currently unknown whether in-hospital outcomes are affected by early (<48 hours) versus late (>48 hours) initiation of CDT from time of admission of patients with PE. The National Inpatient Sample database was queried from the years 2016-2019 to obtain our sample of PE admissions using appropriate ICD-10-CM codes. Those with concurrent acute limb ischemia, ischemic stroke, stenting or bypass procedures in the same admission were excluded. Our cohort was divided into those who underwent early or late intervention with CDT. Outcomes were measured using multivariate logistic regression and propensity score matching to obtain adjusted odds ratios (aOR). 27,435 patients received CDT, of which 22,650 underwent early intervention and 3,935 underwent late intervention. After propensity score matching, no differences in the likelihood of mortality (aOR 0.84, p=0.194) and vasopressor use (aOR 1.04, p=0.863) were found between the two interventions. The late intervention group had higher likelihood of concurrent need for systemic thrombolysis (aOR 1.66, p<0.01), blood transfusions (aOR 1.36, p<0.01), and intubation (aOR 1.31, p=0.01). Delaying CDT in patients with intermediate to high-risk PE led to a greater need for systemic thrombolysis, blood transfusion, and mechanical ventilation but did not lead to increase in-hospital mortality. Future randomized clinical trials should focus on the timing of CDT in PE to further elucidate its effects.

C-43 | Catheter-Directed Thrombolysis versus Thrombectomy for Submassive and Massive Pulmonary Embolism: A Systematic Review and Meta-Analysis

C-43 | Catheter-Directed Thrombolysis versus Thrombectomy for Submassive and Massive Pulmonary Embolism: A Systematic Review and Meta-Analysis

C-46 | In-Hospital Mortality in Patients With Pulmonary Embolism Managed With Ultrasound-Assisted Catheter-Directed Thrombolysis Compared to Systemic Thrombolysis

Patients with high-risk or intermediate-risk pulmonary embolism (PE) require more aggressive therapy, such as systemic thrombolysis. Although parenteral systemic thrombolysis leads to faster clot resolution, it is associated with a high risk for significant bleeding and its complications. The use of catheter-directed thrombolysis (CDT) decreases systemic exposure to thrombolytics and reduces the risk of complications and mortality. Adding ultrasound to CDT can potentially decrease the dosing of local thrombolytics and make it even safer for the patients. This retrospective cohort study identified 1,007 patients diagnosed with pulmonary embolism (PE) across several facilities. Patients were stratified into two groups based on the treatment they received, a group that received systemic thrombolysis (ST), 432 (42.9 %), and a group that received ultrasound-assisted catheter-directed thrombolysis (EKOS), 575 (57.1 %). The aim was to explore immediate mortality from direct and indirect complications arising from PE and its management in patients treated with systemic thrombolysis vs. EKOS. We used logistic regression to analyze data. The patients with PE and who were managed with ST were more likely to expire than those treated with EKOS (OR 2.893, CI 1.766∼5.041, p<0.001). Patients who passed were more likely to experience tachycardia (OR 2.432, CI 1,299∼4.556, p<0.001) and use of vasopressors (OR 13.331, CI 8.075∼22.006, p<0.001). There were 70 (6.95 %) deaths in the ST group vs. 26 (2.58 %) in the EKOS group. Patients with PE managed with ST are more likely to die than those managed with EKOS. This illustrates better outcomes of using EKOS vs. systemic thrombolysis for PE. However, a limitation of this study was the small sample of patients and possible cofounders, which warrants future studies.

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.