Treatment Of Massive Pulmonary Embolism Research Articles

Mortality Outcomes with Tenecteplase Versus Alteplase in the Treatment of Massive Pulmonary Embolism

Mortality Outcomes with Tenecteplase Versus Alteplase in the Treatment of Massive Pulmonary Embolism

Experience in the use of non-immunogenic recombinant staphylokinase in the treatment of massive pulmonary embolism

The actuality of the problem of pulmonary embolism is due to the widespread occurrence of this complication with unpredictable consequences, including hemodynamic instability, arterial hypotension, shock, disability and sudden death. Pulmonary embolism is now considered in developed countries as the most common cause of preventable inhospital death and maternal mortality. Thrombolytic therapy is used for intermediate and high-risk pulmonary embolism with hemodynamic instability of the patient, however, there is also ongoing discussion about the possibilities of its implementation in normotensive patients under certain conditions. Currently, streptokinase, urokinase and alteplase (Actilize and Revelise in Russia) are used for thrombolytic therapy of pulmonary embolism. Indications for use in pulmonary embolism have been expanded recently for the already wellknown domestic thrombolytic non-immunogenic staphylokinase (Fortelizin®), which has proven itself in patients with acute myocardial infarction and acute ischemic stroke. A clinical case of delayed (on the 4th day of hospitalization) use of Fortelisin with a positive effect in a 49-year-old normotensive anemized patient with syncope in the PE debut with non-occlusive thrombosis of the posterior tibial veins without flotation of blood clots is presented. The features of Fortelizin, which favorably distinguish it from other thrombolytic agents, are: the highest fibrin selectivity; the possibility of bolus administration of a fixed dosage, independent of the patient’s body weight; safety of repeated administration; high rate of onset of effect; prevention of a significant decrease in blood fibrinogen levels, which reduces the risk of bleeding. Thus, the use of the domestic thrombolytic recombinant non-immunogenic staphylokinase drug Fortelizin, taking into account the data of the conducted studies and the described case, seems to be a successful example of import substitution in medicine.

First-Line Treatment for Massive Pulmonary Embolism: Counterpoint-Tried-and-True Catheter-Directed Thrombolysis Is a More-Established Therapy for Massive Pulmonary Embolism.

First-Line Treatment for Massive Pulmonary Embolism: Counterpoint-Tried-and-True Catheter-Directed Thrombolysis Is a More-Established Therapy for Massive Pulmonary Embolism.

First-Line Treatment for Massive Pulmonary Embolism: Point-Catheter-Directed Mechanical Thrombectomy May Challenge the Treatment Algorithm.

First-Line Treatment for Massive Pulmonary Embolism: Point-Catheter-Directed Mechanical Thrombectomy May Challenge the Treatment Algorithm.

Role of Extracorporeal Membrane Oxygenation in the Treatment of Massive Pulmonary Embolism

AbstractMassive/high-risk pulmonary embolism (PE) is associated with a 30-day mortality rate of approximately 65%. In searching for strategies that may make a dent on this dismal mortality rate, investigators have, over the last decade, shown renewed interest in the potential beneficial role of venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) in the treatment of patients with high-risk PE. There is a dearth of high-quality evidence regarding the value of ECMO in the treatment of massive PE. Studies examining this issue have generally been retrospective, often single center and frequently with small patient numbers. Moreover, these reported studies are not matched with appropriate controls, and, accordingly, it is difficult to regulate for inherent treatment bias. Not surprisingly, there are no randomized controlled trials examining the value of ECMO in the treatment of massive PE, as such trials would pose formidable feasibility challenges. Over the past several years, there has been increasing support for upfront use of V-A ECMO in the treatment of massive PE, when it is complicated by cardiac arrest. In those patients without cardiac arrest, but who have contraindications for thrombolysis, V-A ECMO combined with anticoagulation may be used to stabilize the patient. If after 3 to 5 days, such patients demonstrate persistent right ventricular dysfunction, embolectomy (either surgical or catheter based) should be performed. Well-designed, multicenter, prospective studies are urgently needed to better define the role of V-A ECMO in the treatment of patients with massive PE.

Simple and secure thrombectomy without circulatory arrest for acute pulmonary embolism

BackgroundSurgical pulmonary artery thrombectomy is a well-established emergency treatment for massive pulmonary embolism (PE) in which fibrinolysis or thrombolysis are not effective. However, surgery for massive PE that requires peripheral pulmonary artery thrombus removal remains challenging. We established a simple and secure pulmonary artery thrombectomy method using cardiopulmonary bypass and cardiac arrest. In this procedure, the surgical assistant arm, typically used for coronary artery bypass grafting, is used to obtain a feasible working space during thrombectomy.Case presentationWe present seven consecutive massive PE cases that were treated with the present surgical method and successfully weaned from cardiopulmonary bypass or extracorporeal membrane oxygenation postoperatively.ConclusionsThis procedure can be used to prevent right ventricular failure after surgery as surgeons can remove the peripheral thrombus with clear vision up to the second branch of the pulmonary artery.

Successful Treatment of Massive Pulmonary Embolism with Rescue Fibrinolysis in Young Patient with Homocystinemia - Case Report

Abstract Pulmonary embolism (PE) is the most frequently missed diagnosis in the urgent clinical department with serious consequences. Patients with unprovoked PE have increased risk of recurrent PE. Approximately 5 to 8% of PE patients have inherited thrombophilias. A solated homocystinemia is a rare cause of unprovoked acute pulmonary embolism. Timely diagnosis and proper treatment can prevent complications, costs and mortality and provide patient better quality of life. We are presenting a 42-year-old woman was admitted to our emergency department with the first episode of severe dyspnea and chest pain. She had no history of previous cardiovascular or respiratory disease and no history of previous pulmonary embolism (PE) or deep vein thrombosis (DVT). Urgent echocardiography showed indirect signs of pulmonary embolism which was confirmed by the pulmonary artery CT angiography performed one day after the patient’s admission. After two days of heparin infusion, she developed a hemodynamic instability with cardiogenic shock and was treated successfully with fibrinolysis. After the clinical stabilization, she was put on the rivaroxaban therapy, which was recommended for additional six months. The thrombophilia profile was done two weeks after stopping the therapy with rivaroxaban. The thrombophilia panel came back positive for high levels of homocysteine (67 μmol/L), with other thrombophilia results within normal limits. The patient was stable during the follow-up period. Pulmonary embolism should be always suspected in younger patients with acute severe dyspnea even without provocable risk factors. High suspicion level and fast diagnosis are lifesaving. In younger patients presented with unprovoked pulmonary embolism, clinicians should consider inherited prothrombotic factors and homocystinemia as a potential cause. Rescue fibrinolysis is a lifesaving therapy in hemodynamic worsening in intermediate high-risk PE patients. A longer anticoagulation therapy should be considered in these cases with novel oral anticoagulants that are recommended as safer and superior therapy.

Extracorporeal membrane oxygenation for the treatment of massive pulmonary embolism. An analysis of the ELSO database

AimExtracorporeal membrane oxygenation (ECMO) may be beneficial in treatment of massive pulmonary embolus (PE), however the current evidence to guide its use is limited. We aimed to compare the incidence, characteristics, treatments, and outcomes of patients with massive PE by mode of ECMO from a large international registry. MethodsRetrospective observational study of the Extracorporeal Life Support Organization (ELSO) database. ResultsA total of 821 patients underwent 833 ECMO episodes for PE. Mean age was 49 (±15) years, 408 (50.1%) were female, and 450 (54.7%) had a cardiac arrest prior to ECMO initiation. Venoarterial (VA) ECMO was the most common mode in 489 (58.7%), followed by extracorporeal cardiopulmonary resuscitation (ECPR) in 229 (27.4%) and venovenous (VV) ECMO in 85 (10.2%). The number of episodes per year increased over the study period, predominantly driven by an increase in ECPR. In-hospital mortality was the highest for ECPR 156/229 (68.1%), followed by VA ECMO 209/498 (42.7%) and VV ECMO 24/85 (28.2%) P < 0.001. After controlling for univariate and clinically significant variables at the time of ECMO initiation, increasing age (OR 1.02 (1.00–1.03), lower pH (OR 0.18 (0.03–0.44), lower diastolic blood pressure (OR 0.99 (0.97–1.00) and ECPR mode (OR 3.67 (1.46–9.230) were independently associated with in-hospital mortality. ConclusionECMO use for massive PE is increasing globally, and overall mortality rates compare favorably with other indications of ECMO. The use of ECPR and worsening metabolic status at initiation were associated with higher in-hospital mortality, suggesting delays in initiating ECMO should be avoided.

Veno-arterial extracorporeal membrane oxygenation versus standard medical management for massive pulmonary embolism.

There is limited research on the use and outcomes of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment for massive pulmonary embolism (PE). This study compared VA-ECMO treatment for massive PE versus patients treated medically. Patients diagnosed with massive PE at one hospital system were reviewed. VA-ECMO and non-ECMO groups were compared by t test and Chi-square. Mortality risk factors were identified by logistic regression. Survival was assessed by Kaplan Meier and propensity matching of groups. Ninety-two patients were included (22 VA-ECMO and 70 non-ECMO). Age (OR 1.08, 95% CI 1.03-1.13), arterial SBP (OR 0.97, 95% CI 0.94-0.99), albumin (OR 0.3, 95% CI 0.1-0.8), and phosphorus (OR 2.0, 95% CI 1.4-3.17) were independently associated with 30-day mortality. Alkaline phosphate (OR 1.03, 95% CI 1.01-1.05) and SOFA score (OR 1.3, 95% CI 1.06-1.51) were associated with 1-year mortality. Propensity matching showed no difference in 30-day (59% VA-ECMO versus 72% non-ECMO, p = 0.363) or 1-year survival (50% VA-ECMO versus 64% non-ECMO, p = 0.355). Patients treated with VA-ECMO for massive PE and medically treated patients have similar short- and long-term survival. Further research is needed to define clinical recommendations and benefits of intensive therapy such as VA-ECMO in this critically ill population.

Commentary to article Il’ya I. Dzidzava et al. «Treatment of massive pulmonary embolism with systemic thrombolysis in the nearest postoperative period»

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Treatment of massive pulmonary embolism with systemic thrombolysis in the nearest postoperative period

In the presented clinical observations, in one patient, acute massive pulmonary embolism developed on the 2nd day after the extended surgical intervention in the colon; in the second case, it developed on the 18th day after the extensive surgical aid against pancreatic necrosis. Clinical predictors of a high risk of death of thromboembolism and the technical impossibility of using another treatment method were the basis for systemic administration of tissue plasminogen activator. The direct result of systemic thrombolysis was the clinical recovery of patients. The hemorrhagic complication diagnosed in one of the observations was in the form of moderate bleeding from a vessel of the gastroenteroanastomosis region. Bleeding was stopped with the minimally invasive endoscopic clipping.

Commentary to article Il’ya I. Dzidzava et al. «Treatment of massive pulmonary embolism with systemic thrombolysis in the nearest postoperative period»

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Hybrid treatment of massive pulmonary embolism by catheter-directed and surgical embolectomy.

Hybrid treatment of massive pulmonary embolism by catheter-directed and surgical embolectomy.

Successful Surgical Treatment of Massive Pulmonary Embolism after Neurosurgical Intervention

Successful Surgical Treatment of Massive Pulmonary Embolism after Neurosurgical Intervention

Massive pulmonary embolism: embolectomy or extracorporeal membrane oxygenation?

To highlight updates on the use of extracorporeal membrane oxygenation (ECMO) and surgical embolectomy in the treatment of massive pulmonary embolism. Outcomes for surgical embolectomy for massive pulmonary embolism have improved in the recent past. More contemporary therapeutic options include catheter embolectomy, which although offer less invasive means of treating this condition, need further study. The use of ECMO as either a bridge or mainstay of treatment in patients with contraindications to fibrinolysis and surgical embolectomy, or have failed initial fibrinolysis, has increased, with data suggesting improved outcomes with earlier implementation in selected patients. Although surgical embolectomy continues to be the initial treatment of choice in massive pulmonary embolism with contraindications or failed fibrinolysis, the use of ECMO in these high-risk patients provides an important tool in managing this often fatal condition.

VENO-ARTERIAL ECMO AS A BRIDGE TO EMERGENT PULMONARY THROMBECTOMY IN A PATIENT WITH CARDIOPULMONARY ARREST

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Massive pulmonary embolism (PE) is associated with a high mortality. Systemic anticoagulation, systemic thrombolytics, and direct surgical thrombectomy are standard therapeutic options. Use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with a massive PE has been retrospectively associated with an improvement in mortality. We report the case of a trauma patient who survived intraoperative cardiopulmonary arrest secondary to a massive saddle PE after being placed on VA-ECMO as a bridge to emergent pulmonary thrombectomy. CASE PRESENTATION: A 31-year-old female presented to our hospital after a motor vehicle accident that resulted in a left femoral head fracture and dislocation, right fibular fracture, a small right temporal subarachnoid hemorrhage, and a left temporal laceration. On the day after admission during the orthopedic surgery, the patient was noted to have significant oxygen desaturation. The patient quickly developed cardiac arrest requiring multiple rounds of CPR. Bedside transthoracic echocardiography identified right ventricular strain with sonographic McConnell sign. While actively undergoing CPR, the patient was emergently placed on ECPR with VA-ECMO. Subsequent CT angiography revealed a massive saddle pulmonary embolism with extensive right and left pulmonary artery involvement. The patient was taken for surgical pulmonary artery thrombectomy with successful removal of large clot burden from the right and left pulmonary arteries, allowing almost immediate post-operative discontinuation of VA-ECMO and vasopressor support. The patient required inotropic support for acute right heart failure that was successfully weaned in the following week. The patient’s hospital course was complicated by rhabdomyolysis and compartment syndrome requiring fasciotomy. She discharged with oral anticoagulation, intact neurologic function, and the ability to ambulate without oxygen. DISCUSSION: A recent descriptive study found that ECMO is being used more often for patients with high-risk PE (0.07% to 1.1%). A retrospective case-control study of 56 patients found a significant improvement in survival for patients with massive PE that were placed on VA-ECMO as a bridge to further intervention compared to a control group (96% vs. 73%). While ECPR is recommended as part of the 2015 American Heart Association ACLS guidelines, this case provides a successful example of ECPR and VA-ECMO that allowed time for definitive management of a reversible cause. CONCLUSIONS: In patients with a massive PE who experience cardiopulmonary arrest, ECPR and VA-ECMO should be considered as an option to bridge the patient to a definitive surgical option. Reference #1: Elbadawi A et al. National trends and outcomes for extra-corporeal membrane oxygenation use in high-risk pulmonary embolism. Vasc Med. 2019 Mar 5:1358863X18824650. https://doi.org/10.1177/1358863X18824650. Reference #2: Pasrija C et al. Triage and optimization: A new paradigm shift in the treatment of massive pulmonary embolism. DISCLOSURES: No relevant relationships by Rohini Chatterjee, source=Web Response No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Thomas Lee, source=Web Response Speaker/Speaker's Bureau relationship with Jansseen Pharmaceuticals Please note: $5001 - $20000 Added 11/19/2018 by Michael Morris, source=Web Response, value=Salary No relevant relationships by Matthew Read, source=Web Response No relevant relationships by Michal Sobieszczyk, source=Web Response No relevant relationships by Preston Sparks, source=Web Response

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.

Triage and optimization: A new paradigm in the treatment of massive pulmonary embolism

BackgroundMassive pulmonary embolism (PE) remains a highly fatal condition. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) and surgical pulmonary embolectomy in the management of massive PE have been reported previously, the outcomes remain less than ideal. We hypothesized that the institution of a protocolized approach of triage and optimization using VA-ECMO would result in improved outcomes compared with historical surgical management. MethodsAll patients with a massive PE referred to the cardiac surgery service between 2010 and 2017 were retrospectively reviewed. Patients were stratified by treatment strategy: historical control versus the protocolized approach. In the historical control group, the primary intervention was surgical pulmonary embolectomy. In the protocol approach group, patients were treated based on an algorithmic approach using VA-ECMO. The primary outcome was 1-year survival. ResultsA total of 56 patients (control, n = 27; protocol, n = 29) were identified. All 27 patients in the historical control group underwent surgical pulmonary embolectomy, whereas 2 of 29 patients in the protocol approach group were deemed appropriate for direct surgical pulmonary embolectomy. The remaining 27 patients were placed on VA-ECMO. In the protocol approach group, 15 of 29 patients were treated with anticoagulation alone and 14 patients ultimately required surgical pulmonary embolectomy. One-year survival was significantly lower in the historical control group compared with the protocol approach group (73% vs 96%; P = .02), with no deaths occurring after surgical pulmonary embolectomy in the protocol approach group. ConclusionsA protocolized strategy involving the aggressive institution of VA-ECMO appears to be an effective method to triage and optimize patients with massive PE to recovery or intervention. Implementation of this strategy rather than an aggressive surgical approach may reduce the mortality associated with massive PE.

PP-404 - Unsuccessful Treatment of Massive Pulmonary Embolism With ECOS Treated With Pulmonary Embolectomy

In this case we present a 50 years of male patient who had massive pulmonary embolism after deep vein thrombosis treated with pulmonary embolectomy after an unsuccesfull treatment of EKOS (EkoSonic Ultrasound-Accelerated Thrombolysis System). This patient presented with complaints of shortness of breath, palpitation, and hypotension (90/60 mm Hg) three weeks after deep vein thrombosis. The electrocardiogram showed sinusal tachycardia, right axis deviation, and right bundle branch block. The chest X-ray showed atelectatic and infiltrated areas, and minimal pleural effusion. Laboratory findings showed elevated D-dimer level (3200 ng/ml). Echocardiography revealed dilated right heart chambers and a thrombus in the right ventricle. Ejection fraction was normal and pulmonary artery pressure was 50 mm Hg. Doppler ultrasound showed no signs of thrombosis. Following the diagnosis of pulmonary thromboembolism, the patient received oxygen therapy and heparin infusion. However, the clinical course did not improve, hemodynamic deterioration continued, and the echocardiographic appearance of the thrombus persisted, so we decided to perform EKOS treatment. But unfortunately we couldn't succesfull and the patient have emergently pulmonary embolectomy operation. Massive thrombus extracted from pulmonary artery which shown in Figure 1. After massive pulmonary embolectomy operation patient recovered and discharged home without any complication.

Успешное хирургическое лечение массивной тромбоэмболии легочной артерии с одномоментным протезированием митрального клапана

Успешное хирургическое лечение массивной тромбоэмболии легочной артерии с одномоментным протезированием митрального клапана