Treatment Of Acute Pulmonary Embolism Research Articles

Wytyczne dotyczące diagnostyki i leczenia ostrej zatorowości płucnej

Wytyczne dotyczące diagnostyki i leczenia ostrej zatorowości płucnej

Pulmonary Embolectomy for Acute Pulmonary Embolism: A Word of Caution.

Pulmonary embolectomy is an effective treatment of acute pulmonary embolism (APE) but not for chronic pulmonary thromboembolism. We described surgical experience of two patients with APE in preexistent unidentified chronic pulmonary thromboembolism. One patient who presented with severe hypoxia but stable hemodynamics underwent successful pulmonary endarterectomy for proximal organized thrombus instead of pulmonary embolectomy. The other patient who required extracorporeal membrane oxygenation for severe hypoxia developed right heart failure because of residual distal organized thrombus after pulmonary embolectomy. Clinical and radiographical presentation of APE in chronic pulmonary thromboembolism mimics APE, and thus, candidates of pulmonary embolectomy should be carefully selected.

Diagnostic and therapeutic models for the management of acute pulmonary embolism: an issue of local available resources

Acute pulmonary embolism (PE) still represents the third leading cause of cardiovascular mortality in developed countries. In this regard, the last European guidelines offer important suggestions on the management of the disease in daily clinical practice but, at the same time, they do not take into account the feasibility of the recommendations according to the local available resources, including the presence or lack of adequate healthcare facilities (cardiological intensive care unit, cath-lab) or specialists (cardiologist available on a 24 h basis, interventional cardiologist, cardiac surgeon, etc.) all over the day. In the real clinical practice, those recommendations should be adapted to the local available resources. The aim of this document is to provide some suggestions regarding the diagnosis and treatment of acute PE, according to the possible available resources in different local circumstances.

3:27 PM Abstract No. 258 Outcomes of mechanical thrombectomy using the Inari FlowTriever system for the treatment of acute pulmonary embolism

To evaluate the outcomes of patients who underwent mechanical thrombectomy using the Inari FlowTriever System for acute pulmonary embolism. Multiple studies have shown mechanical thrombectomy to be safe and effective in treating patients with intermediate-risk PE (evidence of right heart strain without hemodynamic compromise) and, more recently, high-risk PE over a short-term follow-up period. This single-center study evaluates the outcomes of mechanical thrombectomy in treating intermediate-risk and high-risk PE in a diverse patient population. All patients who underwent mechanical thrombectomy using the Inari FlowTriever System between June 2018 and September 2019 for the treatment of acute pulmonary embolism were identified. We report technical success, procedural complications, and short- and long-term outcomes. During the study period, 23 patients underwent 25 interventions for acute PE (14 submassive, 11 massive.) Of the submassive cohort, 5 were classified as low-intermediate risk and 9 as high-intermediate risk. Mean patient age was 57 years (range, 17-85.) 39% (9/23) had a history of cancer or active cancer. 79% (15/19) were found to have concurrent deep vein thrombosis. 26% (6/23) had a contraindication to systemic thrombolysis. Mechanical thrombectomy was successful in 84% (21/25) of the interventions. In successful cases, the average fluoroscopy time was 22.0 minutes. 78% (18/23) of patients survived to hospital discharge. There were three major adverse events; all intraprocedural mortalities related to cardiopulmonary collapse rather than device-related complication. Two additional patients did not survive to hospital discharge. Both had complications related to stroke, the first occurring prior to thrombectomy and the second following thrombectomy. Despite a reasonable rate of technical success, optimal patient selection strategies and long-term benefits of mechanical thrombectomy for the treatment of acute pulmonary embolism have yet to be elucidated.

3:09 PM Abstract No. 256 Comparison of endovascular and noninvasive therapies in acute pulmonary embolism: a PERT experience

Comparing the outcome measures and safety of endovascular therapy (EVT) with anticoagulation (AC) in the treatment of acute pulmonary embolism (PE) utilizing a Pulmonary Embolism Response Team (PERT). Retrospective review of medical records between January 2017 and August 2018 was performed to identify patients with acute massive or submassive PE who were evaluated by the PERT. Included were patients who received AC with or without EVT. Excluded were patients who were treated with IVC filter only. Analysis was performed comparing patients who received AC alone and those who received AC and EVT. A subgroup analysis was performed for patients who were initially admitted to the ICU comparing AC with or without EVT. A total of 207 patients were identified, 4 were excluded as they did not receive AC and were treated only with IVC filters. There were 153 patients in the AC group and 50 in the EVT group. The AC group was significantly older (64.7 ± 16.4 vs. 58.2 ± 16.2 years, P = 0.02) and had a shorter ICU stay (0.97 ± 2.6 vs. 1.4 ± 1.5 days, P <0.001), although only 35.9% (n = 55) of the AC group were admitted to the ICU (compared to 70% (n = 35) in the EVT group, P <0.001). The rate for initial admission to a stepdown unit was 45.8% for the AC group and 16% for the EVT group (P <0.001). There was a 7.2% major hemorrhagic complication rate in the AC group and 6% in the EVT group (P = 1). The minor hemorrhagic complication rate was 1.3% for the AC group and 0% for the EVT (P = 1). When comparing patients who were initially admitted to the ICU, age (61.7 ± 16.7 vs. 57.7 ± 16.9 years, P = 0.2) and ICU stay (2 ± 2.2 vs. 1.9 ± 1.5 days, P = 0.15) were not significantly different between the AC and EVT groups, respectively. The total hospital stay for the AC group in the subgroup analysis was 7.7 ± 10.2 days while the EVT group stay was 6.3 ± 7.4 (P = 0.2). For patients evaluated by the PERT, major hemorrhagic complication rates were not significantly different between AC and EVT, and for patients initially admitted to the ICU, the ICU length of stay was not significantly different.

Outpatient Treatment in Low-Risk Pulmonary Embolism Patients Receiving Direct Acting Oral Anticoagulants Is Associated With Cost Savings.

Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment compared to inpatient DOAC treatment in patients with low risk PE. A retrospective study in patients with DOAC treated low risk PE (simplified pulmonary severity index [sPESI] ≤ 1) admitted to 8 hospitals during 2013-2015. Health care costs were compared in 223(44%) patients treated as outpatients and 287(56%) treated in hospital. Total cost per patient was 8293 EUR in the inpatient group, and 2176 EUR in the outpatient group (p < 0.001). Total costs for inpatients were higher (p < 0.001) compared to outpatients in both subgroups with sPESI 0 and 1. In multivariate analysis, type of treatment (in- or outpatient, p = < 0.001) and sPESI group (0 or 1, p = < 0.001) were associated with total cost below or above median, whereas age (p = 0.565) and gender (p = 0.177) was not. Adherence to guidelines recommending outpatient treatment with DOAC in patients with low risk PE enables significant savings.

Technical efficiency, short-term clinical results and safety of a large-bore aspiration catheter in acute pulmonary embolism - A retrospective case study.

Background:Mechanical thrombectomy plays an important role in the management of acute pulmonary embolism (PE), either when rapid clot dissolution is needed or when thrombolytics are contraindicated. We describe our clinical and technical experience with the FlowTriever mechanical thrombectomy device in patients with acute PE.Materials and Methods:A retrospective analysis was performed on all cases of acute PE treated with the FlowTriever device at a single tertiary care hospital system during the trial period (November 2019–January 2020). Technical and clinical results, including complications, are reported.Results:Technical success was achieved in all eight successive cases (seven cases of submassive and 1 case of massive PE). Mean pulmonary artery pressure (MPAP) improved significantly after mechanical thrombectomy (27.8 ± 6.4 mmHg preprocedure; 20.5 ± 3.8 mmHg postprocedure; 7.3 ± 5.2 mmHg decrease after the procedure; P = 0.016). Hemoglobin levels did not change significantly after mechanical thrombectomy (11.8 g/dl ± 3.4 preprocedure; 9.9 g/dl ± 2.1 postprocedure; P = 0.20). Reduction in MPAP was achieved in 88% of cases (7/8) and hypoxia improved in all the nonintubated patients (7/7). Mortality observed in one patient with a massive central PE, was not related to the procedure. No mortality or procedural complications were observed in patients with submassive PE.Conclusions:The positive initial clinical experience and safety profile using the FlowTriever in the treatment of acute PE suggests, it has the potential to fill the unmet needs of a good mechanical thrombectomy device to treat massive and submassive high-risk PE especially when thrombolytics are contraindicated.

Zatorowość płucna u chorych po krwawieniu do ośrodkowego układu nerwowego — czy optymalizacja leczenia przeciwkrzepliwego jest możliwa?

We here present descriptions of two patients who after bleeding to the central nervous system sustained pulmonary embolisms, and we discuss the therapeutic difficulties connected with the choice of safe antithrombotic treatment in acute pulmonary embolism.

Simultaneous Treatment of Acute Pulmonary Embolism and Deep Venous Thrombosis. A Preliminary Multicentre Experience

Introduction: Venous thromboembolism, which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a global disease burden. New mechanical thrombus removal devices could represent a safe and effective treatment for acute PE, especially in patients with absolute contraindication to thrombolysis, resulting in high technical and clinical success of this procedure[i] . Moreover coexisting DVT could be treated with thrombus removal devices avoiding caval filter deployment. Aim of this study is to assess the feasibility of aspiration mechanical thrombectomy of massive or submassive PE and DVT, in a single session, in patients with contraindications to thrombolysis. Methods: In two centers, from April 2017 to April 2018, we prospectively enrolled all patients with contraindications to thrombolysis, suffering from DVT and massive or submassive PE according to ESC and AHA guidelines, undergone simultaneous mechanical thrombectomy of both pulmonary arteries and deep peripheral veins. All procedures were approved by our institutional review board and a written informed consent was obtained from all patients when possible. Exclusion criteria were: low risk PE and eligibility for first-line thrombolytic treatment. All patients included in the study were proved to have acute PE based on clinical and radiological findings, according to the presence of proximal arterial PE at computed tomography angiography (CTA) and DVT based on ultrasound and CTA. RV/LV ratio was measured from CTA using a four-chamber views on a dedicated workstation, before trombectomy, postoperatively and at 12 months follow-up. SpO2, Heart Rate (HR), and ultrasound venous examination were recorded at 12 months follow-up. Technical success was defined as pulmonary arterial systolic pressure reduction at 50% from the initial value for PE treatment and direct visualisation of thrombus significant reduction (> 70%) in peripheral DVT. Results: Six patients (2 male) were enrolled in our study. Mean age was 76 (55-91). All patients required before treatment high volume O2 therapy, with mean SpO2 of 85.8 (82-90), mean heart rate of 72.5 (42-100) and mean RV/LV of 1.37 (1.2-1.8). Contraindications for first-line thrombolytic treatment were: recent stroke in 4 cases, known bleeding risk in 1 case and brain metastasis in 1 case. Two patients presented popliteal residual DVT, 3 patients femoral DVT and 1 patient iliac DVT. No procedural or periprocedural complications were observed. PE technical success was achieved in all patients, peripheral venous revascularisation was effective in 4 patients, in two patients mechanical aspiration was unable to solve the subacute thrombosis and no further treatment was attempt. At 12 months follow up only 1 patient required 1L O2 therapy with mean SpO2 of 91.8 mmHg (90-94), mean heart rate of 68,3 (63-73) and mean RV/LV ratio of 0,90 (0,85-0,95). Vein ultrasound examination revealed that 4 patients still had patent veins, while in uneffective peripheral veins aspiration a chronic DVT was evident. Conclusion: In our preliminary series simultaneous treatment of DVT and PE is safe and effective. Low rate of complications encourage extensive use of this technique in selected patients, however larger prospective studies are needed to assess the feasibility of this treatment. Disclosure: Nothing ti disclose

Dyspnea Postpulmonary Embolism From Physiological Dead Space Proportion and Stroke Volume Defects During Exercise

Many patients with pulmonary embolism (PE) report dyspnea on exertion following long-term treatment. Increased physiological dead space proportion (VD/VT) and decreased cardiac stroke volume reserve may distinguish persistent effects of PE itself from symptoms reflecting comorbid conditions or deconditioning. This retrospective study analyzed a consecutive series of incremental symptom-limited cardiopulmonary exercise tests that had been ordered to evaluate persistent dyspnea on exertion following long-term treatment for acute PE. Physiological VD/VT was determined at anaerobic threshold from exhaled CO2 and transcutaneous Pco2 (validated against Paco2 measurements). Cardiac stroke volume reserve was estimated at rest and at anaerobic threshold by using oxygen consumption/pulse and previously validated estimates of the arteriovenous oxygen content difference. Cardiopulmonary exercise tests were performed on 40 patients with post-PE dyspnea. In 65.0%(95%CI, 50.2-79.8), VD/VT at anaerobic threshold was abnormally elevated, stroke volume reserve was decreased, or both defects occurred. VD/VT at anaerobic threshold was abnormally elevated (≥ 0.27) in 35.0%(95%CI, 20.2-49.8). VD/VT at anaerobic threshold significantly correlated with the extent of unmatched perfusion defects on subsequent ventilation-perfusion scans (P= .0085). In 55.0%(95%CI, 39.6-70.4), stroke volume reserve at anaerobic threshold was abnormally decreased (≤ 128%of the resting value). Both defects were present in 25.0%(95%CI, 11.6-38.4). Increased VD/VT at anaerobic threshold and decreased stroke volume reserve during exercise are common among patients with dyspnea on exertion after long-term treatment of PE. The defects can be disclosed noninvasively by using cardiopulmonary exercise testing.

Clinical patterns and significance of non-compliance with guideline-recommended treatment of acute pulmonary embolism

Evidence-based clinical practice guidelines define initial management of acute pulmonary embolism (PE) according to risk stratification for early death. The aims of the present study were to investigate patterns of non-compliance with guidelines for the acute PE treatment, and the associated risk of adverse events. We performed an observational, multicentre, cohort study of acute PE. Inclusion criteria were all patients with pulmonary embolism admitted to the participating centres between January 2011 and April 2017. The measure of 100% compliance was used to allocate patients in the compliant or non-compliant groups. The primary outcome was all-cause death at 6 months. Secondary outcomes included recurrent venous thromboembolism and major bleeding. In total, 1285patients were included. Treatment was not in compliance with the guidelines in 172 patients (13.4%). Four factors were identified to be related to non-compliance with the guidelines: shock or hypotension (relative risk [RR] 5.23, 95% confidence interval [CI] 2.64-10.30; P<0.001), renal insufficiency (RR 1.80, 95% CI 1.41-2.28; P<0.001), active cancer (RR 1.35, 95% CI 1.24-1.48; P<0.001) and right ventricular dysfunction at admission (RR 1.06, 95% CI 1.01-1.11; P=0.01). The primary endpoint of all-cause death at 6months occurred in 62 of 172 patients (36.0%) in the non-compliant group and in 131 of 1113 patients (11.8%) in the compliant group (hazard ratio 2.02, 95% CI 1.45-2.81; P<0.001). The rates of recurrent venous thromboembolism (8.7% vs 1.1%; P<0.001) and major bleeding (13.4% vs 4.9%, P=0.04) from admission to 6-month follow-up were higher in the non-compliant group. Non-compliance with guidelines was independently associated with worse outcomes, including death, recurrent venous thromboembolism and bleeding.

FJVIS 8. Simultaneous Treatment of Acute Pulmonary Embolism and Deep Venous Thrombosis

FJVIS 8. Simultaneous Treatment of Acute Pulmonary Embolism and Deep Venous Thrombosis

Is there an optimal "door to cath time" in the treatment of acute pulmonary embolism with catheter-directed thrombolysis?

Ultrasound assisted catheter-directed thrombolysis (UACT) is a relatively novel approach to treating acute pulmonary embolism (PE). It is an alternative to systemic thrombolysis with good success rates and low reported in-hospital mortality, and low rates of procedure-related major and minor bleeding. Since UACT received FDA approval for the treatment of PE in 2014, there is paucity of data regarding the optimal timing of initiation of the procedure after the initial diagnosis is made. We reviewed the available literature regarding UACT for acute PE and found six studies that included time to procedure. Based on our review, patients may benefit from early (<24-48 h after presentation) rather than delayed (>48 h) initiation. Early initiation of therapy has shown to improve pulmonary arterial pressures, right ventricular (RV) to left ventricular (LV) ratios, with low rates of bleeding and low post procedural and in hospital mortality. However, further studies are required to confirm these findings and establish the appropriate timeline for initiation of UACT.

Retracted: Treatment of Acute Pulmonary Embolism: Update on Newer Pharmacologic and Interventional Strategies.

[This retracts the article DOI: 10.1155/2014/410341.].

First - In - Man Study to Assess the Safety and Feasibility of The Bashir™ Endovascular Catheter for the Treatment of Acute Pulmonary Embolism

First - In - Man Study to Assess the Safety and Feasibility of The Bashir™ Endovascular Catheter for the Treatment of Acute Pulmonary Embolism

Therapeutic Advances in Emergency Cardiology: Acute Pulmonary Embolism.

Acute pulmonary embolism (PE) requires rapid diagnosis and early and appropriate treatment, often under conditions of hemodynamic instability. The therapeutic strategy should optimally integrate the therapeutic arsenal in a multidisciplinary but unitary approach. The short list of the major uncertainties associated with acute PE should include limited general public awareness on venous thromboembolism, acute hemodynamic support not based on evidence from randomized clinical trials, with few updates lately, mainly linked to extracorporeal membrane oxygenation, thrombolytic therapy having firm indications only in high-risk PE, without clear strategies for particular clinical situations (ie, stroke, tumors, thrombi in transit, and cardiac arrest), using old therapeutic agents with old administration regimens, lack of evidence from large-volume trials on the optimal interventional approach, and relatively imprecise indications for surgical treatment. We reviewed current data on the diagnosis and therapeutic approach of acute PE. A collaborative idea has been reached: apply the multidisciplinary expertise of a rapid response heart team to patients with PE in Pulmonary Embolism Response Teams. Optimization of acute hemodynamic support involves the cautious use of volume expansion; diuretic treatment may provide early improvement in normotensive patients with acute PE and RV failure, and during massive PE, we may use the venoarterial extracorporeal membrane. Until new data accumulate, rescue reperfusion should be performed only if hemodynamic decompensation develops despite adequate anticoagulation. Only EkoSonic catheter is approved by the FDA in the interventional treatment of acute PE, without the routine use of retrievable inferior vena cava filters. Outcomes of pulmonary embolectomy after an early triage of patients with hemodynamically unstable PE are acceptable. In selected low-risk patients, an ambulatory treatment of PE with DOAC is effective and safe. Nowadays, evidence and ideas have been gathered that can significantly improve the outcome of patients with PE with varying degrees of severity, remaining to demonstrate the cost-effectiveness of this advanced therapeutic approach.

The rationale, design, and methods of a randomized, controlled trial to evaluate the efficacy and safety of an active strategy for the diagnosis and treatment of acute pulmonary embolism during exacerbations of chronic obstructive pulmonary disease

IntroductionSome previous studies have suggested a high prevalence of pulmonary embolism (PE) during exacerbations of chronic obstructive pulmonary disease (ECOPD). The SLICE trial aims to assess the efficacy and safety of an active strategy for the diagnosis and treatment of PE (vs usual care) in patients hospitalized because of ECOPD.MethodsSLICE is a phase III, prospective, international, multicenter, randomized, open‐label, and parallel‐group trial. A total of 746 patients hospitalized because of ECOPD will be randomized in a 1:1 fashion to receive either an active strategy for the diagnosis and anticoagulant treatment of PE or usual care (ie, standard care without any diagnostic test for diagnosing PE). The primary outcome is a composite of all‐cause death, non‐fatal (recurrent) venous thromboembolism (VTE), or readmission for ECOPD within 90 days after enrollment. Secondary outcomes are (a) death from any cause within 90 days after enrollment, (b) non‐fatal (recurrent) VTE within 90 days after enrollment, (c) readmission within 90 days after enrollment, and (d) length of hospital stay.ResultsEnrollment started in September 2014 and is expected to proceed until 2020. Median age of the first 443 patients was 71 years (interquartile range, 64‐78), and 26% were female.ConclusionsThis multicenter trial will determine the value of detecting PEs in patients with ECOPD. This has implications for COPD patient morbidity and mortality. Trial registration number: NCT02238639.

Study on the measurement of cardiac CT in patients with acute pulmonary embolism

Objective To measure and analyze cardiac ventricular sizes of acute pulmonary embolism patients, and compared with normal group, to investigate the morphological changes of heart in patients with acute pulmonary embolism. Methods 75 patients with acute pulmonary embolism were analyzed retrospectively and were divided into two groups according to the score of embolism index: more than or equal to 50% (group c, 33 cases) and less than 50% (group b, 42cases) and compared with normal group (group a, 56 cases) to analyze the changes of cardiac ventricular transversal diameter(LR) and anteroposterior diameter (AP). Results The group c compared with group a and b, the right ventricular LR and AP, and the right atrium LR increased significantly (P 0.05). After the treatment of acute pulmonary embolism, the right ventricular RL×AP is significantly reduced(4 209.57±844.63 vs 5 090.58±1312.69, P=0.002), the ventricle ratio (RV/LV) is significantly reduced(0.80±0.13 vs 0.93±0.19, P=0.003. Conclusions The size and shape of heart cavity varied with different pulmonary embolism index, and we can make preliminary observation and evaluate treatment efficacy by using chest CT scan. Key words: Tomography, X-ray computed; Acute; Pulmonary embolism; Embolism index; Right ventricle; Left ventricle; Right atrium; Left atrium; Measurement

Is there an optimal “door to cath time” in the treatment of acute pulmonary embolism with catheter-directed thrombolysis?

Ultrasound assisted catheter-directed thrombolysis (UACT) is a relatively novel approach to treating acute pulmonary embolism (PE). It is an alternative to systemic thrombolysis with good success rates and low reported in-hospital mortality, and low rates of procedure-related major and minor bleeding. Since UACT received FDA approval for the treatment of PE in 2014, there is paucity of data regarding the optimal timing of initiation of the procedure after the initial diagnosis is made. We reviewed the available literature regarding UACT for acute PE and found six studies that included time to procedure. Based on our review, patients may benefit from early ( 48 h) initiation. Early initiation of therapy has shown to improve pulmonary arterial pressures, right ventricular (RV) to left ventricular (LV) ratios, with low rates of bleeding and low post procedural and in hospital mortality. However, further studies are required to confirm these findings and establish the appropriate timeline for initiation of UACT.

Prognostic impact of non-compliance with guidelines-recommended treatment of acute pulmonary embolism: Results of a prospective multicenter registry

We aimed to describe non-compliance with guidelines and identify predictors of non-compliance; and to evaluate the impact of non-compliance on the occurrence of clinical events. Observational, multicenter, multidisciplinary registry of acute pulmonary embolism (PE). Based on the ESC guidelines, we used the following indicators to assess compliance: – received reperfusion therapy to treat high-risk PE; – appropriate DOAC dose; – LMWH monotherapy for cancer-associated or pregnancy-related PE; – LMWH, fondaparinux and DOACs contraindicated in pts with severe renal failure; – implantation of inferior vena cava filter in pts with acute PE and absolute contra-indication to anticoagulation; – oral anticoagulation for at least 3 months after a first PE; – for pts with PE and cancer, extended anticoagulation (beyond the first 3–6 months) should be considered; – anticoagulation of indefinite duration is recommended for pts with a second unprovoked PE. Pts with 100% compliance were allocated to the compliant group. Primary outcome was 6-month all-cause death. Secondary outcomes were venous thromboembolism (VTE), major bleeding and chronic thromboembolic pulmonary hypertension (CTEPH). 1285 pts were included. Treatment was guidelines-compliant in 1113 (86.6%). Independent predictors of non-compliance were: Shock/hypotension (OR: 5.6; 95% CI: 2.8–10.3); renal insufficiency (OR: 1.6; 95% CI: 1.2–2.0), cancer (OR: 1.21; 95% CI: 1.1–1.3) and RV dysfunction (OR: 1.08; 95% CI 1.03–1.1). All-cause death occurred in 62/172 pts (36.1%) vs. 131/1113 (11.8%), non-compliant vs. compliant, (RR 2.02, 95% CI 1.45–2.81; P < 0.001) ( Fig. 1 ). Follow-up rates of recurrent VTE (7.0% vs. 1.3%, P < 0.001) and major bleeding (13.4% vs. 4.8%, P = 0.04) were higher in the non-compliant group. The rate of CTEPH was similar between groups ( P = 0.79). Non-compliance with guidelines was associated with worse outcomes including death, recurrent VTE and bleeding.