Treatment Of Acute Pulmonary Embolism Research Articles

Clinical, Functional, and Quality-of-Life Outcomes after Computer Assisted Vacuum Thrombectomy for Pulmonary Embolism: Interim Analysis of the STRIKE-PE Study

PurposeTo report the first interim analysis of the STRIKE-PE study, evaluating the safety and effectiveness of computer assisted vaccum thrombectomy (CAVT) for the treatment of acute pulmonary embolism (PE). Materials and MethodsThis prospective, international, multicenter study will enroll 600 adult patients with acute PE of ≤14 days and a right ventricle (RV)–to–left ventricle (LV) ratio of ≥0.9 who receive first-line endovascular treatment with CAVT using the Indigo Aspiration System (Penumbra, Alameda, California). Primary endpoints are change in RV/LV ratio and incidence of composite major adverse events (MAEs) within 48 hours. Secondary endpoints include functional and quality-of-life (QoL) assessments. ResultsThe first 150 consecutive patients were treated with 12F catheter CAVT. Mean age was 61.3 years, 54.7% were men, 94.7% presented with intermediate-risk PE, and 5.3% presented with high-risk PE. Median thrombectomy and procedure times were 33.5 minutes and 70.0 minutes, respectively, resulting in a mean reduction in systolic pulmonary artery pressure of 16.3% (P < .001). Mean RV/LV ratio decreased from 1.39 to 1.01 at 48 hours, a 25.7% reduction (P < .001). Four (2.7%) patients experienced a composite MAE within 48 hours. At 90-day follow-up, patients exhibited statistically significant improvements in the Borg dyspnea scale score and QoL measures, and the New York Heart Association class distribution returned to that reported before the index PE. ConclusionsInterim results from the STRIKE-PE study demonstrate a significant reduction in pulmonary artery pressure and RV/LV ratio, a median thrombectomy time of 33.5 minutes, a composite MAE rate of 2.7%, and significant improvements in 90-day functional and QoL outcomes.

Recombinant hirudin attenuates pulmonary hypertension and thrombosis in acute pulmonary embolism rat model.

Acute pulmonary embolism (APE) is classified as a subset of diseases that are characterized by lung obstruction due to various types of emboli. Current clinical APE treatment using anticoagulants is frequently accompanied by high risk of bleeding complications. Recombinant hirudin (R-hirudin) has been found to have antithrombotic properties. However, the specific impact of R-hirudin on APE remains unknown. Sprague-Dawley (SD) rats were randomly assigned to five groups, with thrombi injections to establish APE models. Control and APE group rats were subcutaneously injected with equal amounts of dimethyl sulfoxide (DMSO). The APE+R-hirudin low-dose, middle-dose, and high-dose groups received subcutaneous injections of hirudin at doses of 0.25 mg/kg, 0.5 mg/kg, and 1.0 mg/kg, respectively. Each group was subdivided into time points of 2 h, 6 h, 1 d, and 4 d, with five animals per point. Subsequently, all rats were euthanized, and serum and lung tissues were collected. Following the assessment of right ventricular pressure (RVP) and mean pulmonary artery pressure (mPAP), blood gas analysis, enzyme-linked immunosorbnent assay (ELISA), pulmonary artery vascular testing, hematoxylin-eosin (HE) staining, Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) staining, immunohistochemistry, and Western blot experiments were conducted. R-hirudin treatment caused a significant reduction of mPAP, RVP, and Malondialdehyde (MDA) content, as well as H2O2 and myeloperoxidase (MPO) activity, while increasing pressure of oxygen (PaO2) and Superoxide Dismutase (SOD) activity. R-hirudin also decreased wall area ratio and wall thickness to diameter ratio in APE rat pulmonary arteries. Serum levels of endothelin-1 (ET-1) and thromboxaneB2 (TXB2) decreased, while prostaglandin (6-K-PGF1α) and NO levels increased. Moreover, R-hirudin ameliorated histopathological injuries and reduced apoptotic cells and Matrix metalloproteinase-9 (MMP9), vascular cell adhesion molecule-1 (VCAM-1), p-Extracellular signal-regulated kinase (ERK)1/2/ERK1/2, and p-P65/P65 expression in lung tissues. R-hirudin attenuated pulmonary hypertension and thrombosis in APE rats, suggesting its potential as a novel treatment strategy for APE.

Anticoagulation in the Management of Acute Pulmonary Embolism—A Review

AbstractVenous thromboembolism (VTE) is a very frequent cardiovascular entity that encompasses deep vein thrombosis and pulmonary embolism (PE). This last entity represents a major cause of cardiovascular morbidity and mortality. The incidence of PE and the rate of PE-related morbidity significantly increase with age, race, and underlying medical conditions, such as malignancy. Given the recent advances in diagnostic strategies and algorithms, patients can be risk assessed and treated promptly to avoid disease progression. Anticoagulation is the mainstay of treatment for acute PE that is not hemodynamically unstable. Direct oral anticoagulants, such as apixaban, rivaroxaban, or edoxaban, are currently the preferred agents for the treatment of patients who present with acute PE or for long-term treatment. Treatment duration should be continued for at least 3 months, and all patients should be assessed for extended duration of therapy based on the precipitating factors that led to the development of the VTE. Novel anticoagulant agents targeting factor XI/XIa are currently being investigated in phases 2 and 3 clinical trials, representing an attractive option in anticoagulation therapies in patients with VTE. For hemodynamically unstable patients, systemic thrombolysis is the treatment of choice, and it may also be of benefit—in reduced dose—for patients with intermediate to high risk who are at risk of hemodynamic collapse.

Racial Disparities and Other Socioeconomic Predictors of Mortality in Acute Pulmonary Embolism Treatment from the National Inpatient Sample

PurposeTo explore the significance of socioeconomic factors such as race and ethnicity as predictors of mortality in submassive and massive acute pulmonary embolism (PE). Materials and MethodsHospitalizations of patients aged >18 years with acute, nonseptic PE from 2016 to 2019 were identified from the National Inpatient Sample and divided into interventional radiology (IR) (catheter-directed thrombolysis and thrombectomy) and non-IR (tissue plasminogen activator) treatments. Statistical analyses calculated significant odds ratios (ORs) via 95% confidence intervals (CIs). The primary outcome of interest was mortality rate. Comorbidities affecting mortality were examined secondarily. ResultsNon-Hispanic (NH) Black, Hispanic, and Asian/Pacific Islander patients were significantly less likely to undergo an IR procedure for acute, nonseptic PE compared with White patients (NH Black, OR, 0.83 [95% CI, 0.76–0.90], P < .05; Hispanic, 0.78 [0.68–0.89], P = .06; Asian/Pacific Islander, 0.71 [0.51–0.98], P = .72); however, these differences were eliminated when propensity score matching was performed for age, biological sex, and primary insurance type or for primary insurance type alone. NH Black patients were significantly more likely to die than White patients, regardless of undergoing non-IR or IR treatment. Overall risk of death was 41% higher for NH Black patients than for White patients (relative risk, 1.41 [95% CI, 1.24–1.60]; P < .001). ConclusionsNH Black patients have a higher risk of mortality from acute, nonseptic PE than White patients. Independent of race, undergoing IR management for acute, nonseptic PEs was associated with a lower mortality rate. Matching for primary insurance type eliminates differences in mortality between races, suggesting that socioeconomic status may determine outcomes in acute PE.

The effect of off-label use of reduced-dose direct oral anticoagulants therapy in the treatment of pulmonary embolism comparable to standard-dose therapy

Direct oral anticoagulants (DOACs) have been shown to be effective and safe in preventing pulmonary embolism recurrence. In this single-center retrospective observational study, we aimed to evaluate the efficacy and safety of reduced-dose DOACs in 86 consecutive patients with acute pulmonary embolism. Patients were divided into standard-dose and reduced-dose DOACs groups. Initial clot volume did not significantly differ between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 18.8 [Q1–Q3 7.3–30.8] mL vs. 10.0 [Q1–Q3 3.2–27.9] mL, p = 0.1). Follow-up computed tomography (CT) within 30 days showed a higher rate of clot volume reduction or disappearance in the standard-dose group compared to the reduced-dose group (standard-dose DOACs vs. reduced-dose DOACs, 81.6% vs. 53.9%, p = 0.02). However, at the final follow-up CT, there was no significant difference in clot volume change between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 91.5% vs. 82.0%, p = 0.19). Major bleeding occurred in two patients in the standard-dose group (4.3%) and three patients in the reduced-dose DOACs group (7.7%) (p = 0.5). In conclusion, while standard-dose DOACs demonstrated superior efficacy in early clot reduction, reduced doses of apixaban and edoxaban showed comparable efficacy and safety profiles in long-term treatment of acute pulmonary embolism in certain patients.

Treatment of acute pulmonary embolism after catheter-directed thrombolysis with dabigatran vs warfarin: Results of a multicenter randomized RE-SPIRE trial

BackgroundThrombolytic therapy is effective method in the high-risk acute pulmonary embolism (PE) treatment. Reduced-dose thrombolysis (RDT) plus oral anticoagulation therapy is effective and safe method in the moderate and severe PE treatment. It is leading to good early and intermediate-term outcomes. In the RE-COVER and RE-COVER II studies, dabigatran showed similar effectiveness as warfarin in the treatment of acute PE. Dabigatran leads to fewer hemorrhagic complications and is not inferior in efficacy to warfarin in the prevention of PE after mechanical fragmentation and RDT (catheter-directed treatment [CDT]+RDT) in patients with high and intermediate to high PE risk. We sought to evaluate the efficacy and safety (incidence of clinically significant recurrence of venous thromboembolic complications and deaths) during a 6-month course of treatment with dabigatran or warfarin in patients with high and intermediate to high acute PE risk after endovascular mechanical thrombus fragmentation procedure with RDT (CDT+RDT). MethodsThe RE-SPIRE is a prospective, multicenter randomized double-arm study. Over a 5-year period, 66 consecutive patients with symptomatic high and intermediate to high PE risk after endovascular mechanical thrombus fragmentation procedure with RDT (CDT+RDT) were randomized into two groups within the next 48 hours. The first group continued treatment with dabigatran 150 mg twice a day for 6 months; the second group continued treatment with warfarin under the control of international normalized ratio (2.0-3.0) for 6 months. Both groups received low molecular weight heparins for 2 days after surgery. Then, group 1 continued to receive low molecular-weight-heparin for 5 to 7 days, followed by a switch to dabigatran at a dosage of 150 mg two times a day. Group 2 received both low-molecular-weight heparin and warfarin up to an international normalized ratio of >2.0, followed by heparin withdrawal. The follow-up period was 6 months. ResultsThere were 63 patients who completed the study (32 in the dabigatran group and 31 in the warfarin group). In both groups, there was a statistically significant decrease in the mean pulmonary artery pressure. The mean pulmonary artery pressure at the 6-month follow-up after surgery was 24 mm Hg (interquartile range, 20.3-29.25 mm Hg) in the dabigatran group and 23 mm Hg (interquartile range, 20.0-26.3 mm Hg) in the warfarin group. The groups did not differ statistically in the deep vein thrombosis dynamics. Partial recanalization occurred in 52.0% vs 73.1% in the dabigatran and warfarin groups, respectively (P = .15). Complete recanalization occurred in 28.0% vs 19.2% in the dabigatran and warfarin groups, respectively (P = .56). The groups did not differ in the frequency of major bleeding events according to the International Society for Thrombosis and Hemostasis (0% vs 3.2% in the dabigatran and warfarin groups, respectively; P = 1.00). However, there were more nonmajor bleeding events in the warfarin group than in the dabigatran group (16.1% vs 0%, respectively; P = .02). ConclusionsThe results of the study show that dabigatran is comparable in effectiveness to warfarin. Dabigatran has greater safety in comparison with warfarin in the occurrence of all cases of bleeding in the postoperative and long-term periods. Thus, dabigatran may be recommended for the treatment and prevention of PE after CDT with RDT in patients with high and intermediate to high PE risk.

Curcumin alleviates myocardial inflammation, apoptosis, and oxidative stress induced by acute pulmonary embolism by regulating microRNA-145-5P/insulin receptor substrate 1 axis.

The treatment of patients with acute pulmonary embolism (APE) is extremely challenging due to the complex clinical presentation and prognosis of APE related to the patient's hemodynamic status and insufficient arterial blood flow and right ventricular overload. Protective efficacy against cardiovascular diseases of curcumin, a common natural polyphenolic compound, which has antithrombotic properties and reduces platelet accumulation in the circulation by inhibiting thromboxane synthesis has been demonstrated. However, the direct effect of curcumin on APE has rarely been studied. Therefore, the present study aimed to investigate the therapeutic potential of curcumin in APE and associated myocardial injury to provide new insights into curcumin as a promising competitive new target for the treatment of APE. A suspension of 12 mg/kg microspheres was injected intravenously into rats. An APE rat model was built. Before modeling, intragastric 100 mg/kg curcumin was given, and/or lentiviral plasmid vector targeting microRNA-145-5p or insulin receptor substrate 1 (IRS1) was injected. Pulmonary artery pressure was measured to assess right ventricular systolic pressure (RVSP). Hematoxylin and eosin (H&E) staining was performed on liver tissues and myocardial tissues of APE rats. TUNEL (terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling) staining and immunohistochemical (IHC) staining were conducted to measure apoptosis and CyPA-CD147 expression in the myocardium, respectively. Inflammatory indices interleukin-1beta (IL-1β), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) were measured by ELISA in cardiac tissues. RT-qPCR and Western blot were performed to determine the expression levels of related genes. In addition, by dual luciferase reporter assay and RIP assay, the relationship between microRNA-145-5p and insulin receptor substrate 1 (IRS1) was confirmed. In results: curcumin improved APE-induced myocardial injury, reduced myocardial tissue edema, and thrombus volume. It attenuated APE-induced myocardial inflammation and apoptosis, as well as reduced lung injury and pulmonary artery pressure. Curcumin promoted microRNA-145-5p expression in APE rat myocardium. MicroRNA-145-5p overexpression protected against APE-induced myocardial injury, and microRNA-145-5p silencing abolished the beneficial effects of curcumin in APE-induced myocardial injury. IRS1 was targeted by microRNA-145-5p. IRS1 silencing attenuated APE-induced myocardial injury, and enhanced therapeutic effect of curcumin on myocardial injury in APE rats. In conclusion, curcumin alleviates myocardial inflammation, apoptosis, and oxidative stress induced by APE by regulating microRNA-145-5p/IRS1 axis.

Retracted: Catheter Directed Thrombolysis in the Treatment of Acute Pulmonary Embolism: Early Hemodynamic Recovery and Improvement in Prognosis

Retracted: Catheter Directed Thrombolysis in the Treatment of Acute Pulmonary Embolism: Early Hemodynamic Recovery and Improvement in Prognosis

Utility of TAPSE/sPAP Ratio in Acute Pulmonary Embolism as Valuable Prognostic Marker as PESI Score

Introduction: The pulmonary embolism severity index (PESI) score is used to determine the risk of mortality and severity of complications in acute pulmonary embolism (APE). Tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/sPAP) ratio has been recently shown to predict poor 30-day clinical outcome in APE. We aimed to analyze the prognostic value of the TAPSE/sPAP ratio for prediction of 30-day adverse clinical outcomes in APE patients, similar to PESI score. Patients and Methods: This study enrolled 203 retrospectively evaluated patients (female 108, mean age= 57.4 ± 15.5 years) with the diagnosis of APE between 2010 and 2020. All patients underwent transthoracic echocardiography before specific APE treatment. Primary endpoints were 30-day mortality, thrombolytic therapy requirement, mechanical ventilation requirement, mental status deterioration, and persistent hypotension (systolic blood pressure &lt;90 mmHg). The study population was divided into two groups according to the TAPSE/sPAP ratio= 114 patients in group 1 with a low TAPSE/sPAP ratio (&lt;0.494) and 89 patients in group 2 with a high TAPSE/sPAP ratio (&gt;0.494). Results: The incidence of in-hospital mortality (4.4 vs. 0%, p= 0.045], 30-day mortality [n= 8 (7.0%); 0 (0%), p= 0.009] and primary adverse outcomes (35.1 vs. 0%, p&lt; 0.001) were higher in group 1. The TAPSE/sPAP ratio was negatively correlated with PESI (r= -0.716, p&lt; 0.001). In multivariate logistic regression analyses revealed that the TAPSE/sPAP ratio [OR= 0.001, 95C% CI= 0.000-0.476, p= 0.028] was an independent predictor of 30-day mortality in APE. Conclusion: The present study showed that the TAPSE/sPAP ratio may be used in clinical practice for the prediction of short-term adverse outcome risk estimation in APE patients, similar to PESI score.

Catheter-directed therapy for treatment of acute pulmonary embolism in a teenage patient: The role of close cooperation between the Pulmonary Embolism Response Team and pediatric physicians.

Catheter-directed therapy for treatment of acute pulmonary embolism in a teenage patient: The role of close cooperation between the Pulmonary Embolism Response Team and pediatric physicians.

Pulmonary vasoconstriction plays a major role in the acute phase of pulmonary embolism in pigs

Abstract Background Pulmonary vascular resistance (PVR) increases in acute pulmonary embolism (PE) due to both mechanical obstruction and pulmonary vasoconstriction. Attenuation of adverse pulmonary vasoconstriction has shown promise as a treatment of acute PE in experimental studies. However, clinical trials have failed to replicate these beneficial effects in PE patients. Time may be a factor in this discrepancy between experimental and clinical studies. In experimental PE studies, PVR acutely increases and decreases within hours. Meanwhile in clinical trials, the time from symptom onset to study inclusion is often days, at which time PVR may already be decreased. Whether this decrease in PVR is due to reduced mechanical obstruction by endogenous fibrinolysis or attenuation of adverse pulmonary vasoconstriction is unknown. Purpose To investigate the contribution of the mechanical obstruction and pulmonary vasoconstriction to PVR in two days following PE in pigs. Methods In a controlled animal study, using an estabilished model of autologous PE in pigs (PE, n=12 ∼60 kg), changes in pulmonary hemodynamics and clot burden were evaluated. CT pulmonary angiograms were performed at baseline (BL), after acute PE and the following two days, quantifying clot burden using the Qanadli Obstruction Score. Hemodynamics were evaluated with real-time biventricular catheterization and systemic invasive pressures. To evaluate the vasoactive component, pulmonary vasodilators sildenafil (bolus 0.1 mg/kg) and oxygen (inspired fraction of oxygen 40%) were administered. Results Following PE, both mean PVR (Figure 1A) and pulmonary obstruction scores (Figure 1B) increased. PVR decreased at day one and remained unchanged at day two (Figure 1A). Meanwhile, mean obstruction score decreased slightly at day one but remained elevated throughout the study (Figure 1B). Vasodilatation induced by sildenafil and oxygen (SIL+OXY) decreased PVR at day zero but displayed no effect on the subsequent days (Figure 1A). Conclusion Pulmonary vasoconstriction and mechanical obstruction both contributed to the increase in PVR during the acute phase of PE. PVR decreased towards levels of baseline already day one and remained unchanged at day two. The contribution of pulmonary vasoconstriction decreased at day one and two, while the mechanical obstruction remained significantly increased. Accordingly, the effects of pulmonary vasodilators were only present in the acute phase of PE.Figure 1

Large-bore mechanical thrombectomy for intermediate- and high-risk pulmonary embolism: interim outcomes from the European cohort of the FLASH registry

Abstract Background/Introduction Mechanical thrombectomy is utilized for the treatment of acute pulmonary embolism (PE), but reported outcomes are limited in the European patient population. Purpose To report interim results from the European cohort of a large, prospective all-comer registry of mechanical thrombectomy for PE treatment. Methods The FLASH registry is a multinational, prospective, observational study of safety and effectiveness outcomes for PE treatment using a large-bore mechanical thrombectomy system. FLASH is currently enrolling up to 200 patients in Europe. The primary endpoint is a composite of Major Adverse Events (MAEs) within 48 hours, including device-related deaths, major bleeding, and intraprocedural AEs. Additional assessments include invasive hemodynamics, hospital resource usage, and dyspnea improvement. Results Interim results through 48 hours post-thrombectomy are presented for the first 29 patients enrolled in the European cohort across 4 institutions. Mean patient age was 64.9±14.5 years, 51.7% of patients were male, 10.3% were contraindicated for thrombolysis, 51.7% had concomitant deep vein thrombosis, and 79.3% had centrally located thrombus involving one or both main pulmonary arteries. Per ESC guidelines, 58.6% of patients were classified as high-risk. The remaining 41.4% of patients were classified as intermediate-risk, with 31.0% being intermediate-high-risk. Pre-thrombectomy, the median RV/LV ratio from a composite of computed tomography and echocardiography was 1.31 [IQR: 1.08-1.44], and 38.9% of patients who had cardiac index (CI) measured were in cardiogenic shock (CI ≤2 L/min/m²). Procedural characteristics included a median thrombectomy time of 39 minutes [IQR: 26-49]. Extracorporeal membrane oxygenation was used in 6.9% of patients. Post-thrombectomy, the median length of stay in the intensive care unit (ICU) was 1 overnight [IQR: 0-2], and 48.1% of patients required no overnight ICU stay. In addition, hemodynamic variables, vitals, dyspnea symptoms, and reliance on supplemental oxygen all improved significantly post-thrombectomy (Table 1). Acute safety and mortality outcomes were highly favorable following the procedure (Table 2). All patients survived through 48 hours post-thrombectomy. There were no MAEs (0%), no major access site complications (0%), and no device-related Serious AEs (0%) through 48-hour follow-up. Conclusions Interim results from the first 29 patients in the European cohort of the FLASH registry suggest that large-bore mechanical thrombectomy can be safely performed in both intermediate- and high-risk PE patients, with no MAEs or mortalities observed through 48 hours. Significant improvements observed in multiple hemodynamic and dyspnea-related variables further suggest that thrombectomy can offer effective reperfusion treatment for acute PE.

Abstract 15011: Recent Trends in Interventional Treatment of Acute Pulmonary Embolism and Their Implications for a National Healthcare System

Introduction: Catheter-directed treatment (CDT) of acute pulmonary embolism (PE) is gaining popularity in Europe, following a trend that originated earlier in the US. For healthcare systems, reimbursement of CDT depends on their clinical benefits along with assessing the impact on hospital costs. Hypothesis-Aims: To estimate how increasing use of CDT, as reflected by prospective US data, may affect costs of PE treatment in the German hospital remuneration system (G-DRG). Methods: We analyzed data from the German nationwide inpatient sample (Federal Statistical Office), covering all hospitalizations for PE, for the years 2018-2019. For the same period, we analyzed prospective patient-level data from the multicenter US registry of the Pulmonary Embolism Response Team (PERT) Consortium. Results: During the study period, 196,167 patients were hospitalized for acute PE in Germany. Of these, 64,056 (33%) had intermediate-risk or high-risk PE, but overall ≤ 1% received CDT. Median reimbursement was є3,572 (IQR, 2,804-5,869), corresponding to є4,088 in inflation-adjusted 2022 currency ($5,678, adjusted for purchase parity power). Of 1,349 patients with intermediate- or high-risk PE included in the US registry in 2018-2019, 284 (21%) received CDT, mostly aspiration thrombectomy (63/1,349; 4.7%), ultrasound-assisted catheter thrombolysis (151; 11.2%), or non-assisted catheter thrombolysis (47; 3.5%). Median length of stay was 4.5 (2.8-8.2) days. Based on current reimbursement rates in the G-DRG, fees for PE treated with aspiration thrombectomy amount to є12,179-15,753, and for catheter-directed thrombolysis (with or without ultrasound) to є9,858-13,829. Considering, (a) the shorter length of stay; (b) the proportion of patients receiving CDT in the elevated-risk US cohort in 2018-19; and (c) that of intermediate- and high-risk PE in the German PE inpatient sample, average remuneration per patient would rise from currently є4,088 to є4,724 ($6,552). Conclusions: CDT for PE patients at elevated risk would currently lead to a 16% increase in average per-patient hospital costs in Germany. Together with clinical validation of CDT in ongoing studies, these estimates may inform decision making on reimbursement of interventional treatment options.

Abstract 16030: Efficacy and Safety of Catheter Directed Thrombolysis in Intermediate to High-Risk Pulmonary Embolism: A Meta-Analysis of Randomized Trials

Background: Systemic anticoagulation (SA) is the standard treatment for acute pulmonary embolism (PE). The role of catheter directed thrombolysis (CDT) in addition to SA in intermediate-high risk PE remains unclear. Methods: Three randomized controlled trials comparing CDT+SA versus SA alone in intermediate-high risk PE were included in the analysis using databases including Embase, PubMed and Cochrane databases (inception June 01, 2023). The primary outcome was 90-day all-cause mortality. The secondary outcomes were major bleeding, number of patients with RV/LV ratio &gt;0.9 at 3 months, and vascular access complication. The outcomes were reported as relative risk (RR) with a 95% confidence interval (CI) using random effects model. Results: The analysis comprised of 179 patients with 88 in the CDT group and 79 in the SA group. There was no significant difference in 90-day all-cause mortality (RR: 0.19, 95% CI, 0.02-1.64, p=0.30) among both the groups. Similarly there was no significant difference in major bleeding (RR: 1.20, 95% CI, 0.03-46.18 p= 0.92), RV/LV ratio &gt;0.9 at 3 months (RR: 0.70, 95% CI, 0.41-1.21p=0.2) and vascular access complications (RR: 2.51, 95% CI, 0.44-14.35 p= 0.30). Conclusions: Our study found no significant advantage of CDT+SA versus SA alone in patients with intermediate-high risk PE. Given the scarcity of randomized data, we emphasize the need for a large-scale randomized trial to investigate the long-term effects of CDT in this population.

Can GRACE Risk Score Predict Mortality and the Need for Thrombolytic Treatment in Acute Pulmonary Embolism?

Acute coronary syndrome and pulmonary embolism (PE) are clinical entities sharing similar presentation and risk factors. Risk scores and indexes help to identify disease severity in both diseases. In this study, we aimed to evaluate if the Global Registry of Acute Coronary Events (GRACE) risk score could predict 30-day mortality and the need for thrombolytic treatment in patients with acute PE. Patients hospitalized with a diagnosis of PE in our tertiary center between January 2018 and May 2022 were included in this retrospective study. Pulmonary Embolism Severity Index (PESI) and GRACE risk scores on admission were calculated using clinical, electrocardiographic, and laboratory parameters for each patient. A total of 197 patients were included. The 30-day mortality rate was 28.4% whereas 32.5% of the patients required thrombolytic treatment. GRACE and PESI scores were found independent risk factors associated with 30-day mortality and the need for thrombolytic treatment. A cut-off value of 160.5 for GRACE score was associated with 88.5% sensitivity and 89.4% specificity in prediction of 30-day mortality. In contrast, GRACE score had 61.0% sensitivity and 60.0% specificity in the prediction of the need for thrombolytic treatment when the cut-off value was 147. In conclusion, GRACE risk score has an effective discriminating power in determining the early mortality of patients with acute PE. The incidence of short-term PE-related mortality was significantly increased in patients with high GRACE risk scores. Concomitant use of GRACE and PESI risk scores may aid in defining patients with high-risk PE and help predict poor prognosis with high specificity and probability.

OC 40.2 Outcomes of Home Treatment of Acute Pulmonary Embolism in Clinically Relevant Patient Subgroups: A Systematic Review and Individual-Patient Data Meta-Analysis

OC 40.2 Outcomes of Home Treatment of Acute Pulmonary Embolism in Clinically Relevant Patient Subgroups: A Systematic Review and Individual-Patient Data Meta-Analysis

Initial results of investigator initiated international database on catheter directed therapy of acute pulmonary embolism.

Catheter directed therapies (CDT) are widely used in the treatment of acute pulmonary embolism (PE). A multicenter registry was organized to evaluate their application in real life and to determine efficacy and safety of these procedures. Local experience of participating centers in percutaneous techniques for PE treatment was assessed. An internet-based registry was designed to collect clinical, echocardiographic and laboratory data of consecutive PE patients treated with CDT in participating centers between 2017 and 2022. Under analysis were 145 consecutive patients with acute PE, aged 61 ± 15 years, treated with CDT in 7 centers: 50 (34.5%) patients with high-risk PE (HRPE), and 95 (65.5%) patients with intermediate-high risk PE (IHRPE). 100 (69%) patients were treated with dedicated devices, in 45 (31%) subjects a pigtail catheter was used. Total PE or CDT related in-hospital mortality in HRPE reached 14% (7 patients), while in IHRPE 3.2% (3 patients) (p = 0.032). 50% of PE or CDT related deaths occurred in patients treated with a pigtail catheter. All-cause mortality in 145 patients was 9.7%, and it was higher in HRPE than in IHRPE (18% vs. 5.3%, p = 0.019). The use of pigtail catheters compared to dedicated systems was associated with higher mortality (20% vs. 5%, p = 0.01). Catheter directed therapies is a real option of treating PE. It was used as primary therapy also in patients without contraindication for thrombolysis suggesting that clinical practice does not always follow current PE guidelines. Patients treated with dedicated CDT systems had a higher survival rate than subjects treated with pigtail catheters.

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

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

Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up.

High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.

Outcomes of catheter-directed thrombolysis versus systemic thrombolysis in the treatment of pulmonary embolism: a meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) versus systemic thrombolysis (ST) in the treatment of pulmonary embolism (PE). The Cochrane Library, PubMed, and Embase databases were searched to collect the literature on the comparison of the results of CDT and ST in the treatment of PE from the beginning of their records to May 2020, and meta-analysis was performed by STATA software (version 15.1). Using standardized data-collection forms, the authors screened the studies and independently extracted data, and assessed the quality of the studies using the Newcastle-Ottawa Scale for cohort studies. Cohort studies that examined the following results were included in the current study: in-hospital mortality, all-cause bleeding rate, gastrointestinal bleeding rate, intracranial hemorrhage rate, the incidence of shock, and hospital length of stay. A total of eight articles, with 13,242 participants, involving 3962 participants in the CDT group and 9280 participants in the ST group were included. CDT compared with ST in the treatment of PE can significantly affect in-hospital mortality rate [odds ratio (OR) = 0.41, 95% CI: 0.30-0.56, P < 0.05], all-cause bleeding rate (OR = 1.20, 95% CI: 1.04-1.39, P = 0.012), gastrointestinal bleeding rate (OR = 1.43, 95% CI: 1.13-1.81, P = 0.003), the incidence of shock (OR = 0.46, 95% CI: 0.37-0.57, P < 0.05), and hospital length of stay [standard mean difference (SMD) = 0.16, 95% CI: 0.07-0.25, P < 0.05]. However, there was no significant effect on intracranial hemorrhage rate in patients with PE (OR = 0.70, 95% CI: 0.47-1.03, P = 0.070). CDT is a viable alternative to ST in the treatment of PE, as it can significantly reduce in-hospital mortality rate, all-cause bleeding rate, gastrointestinal bleeding rate, and incidence of shock. However, CDT may prolong hospital length of stay to a certain extent. Further research is needed to evaluate the safety and efficacy of CDT and ST in the treatment of acute PE and other clinical outcomes.