A retrospective analysis of catheter-based thrombolytic therapy for acute submassive and massive pulmonary embolism

Abstract

Catheter-based thrombolysis (CBT) is emerging as an option for acute pulmonary embolism (PE). Although prior studies have demonstrated improvement in right ventricular function, little data is available regarding clinical patient outcomes. Our institution adopted CBT as an option for patients with submassive and massive PE and we evaluated its effect on patient outcomes. Two hundred and twenty-one patients who presented to our institution with submassive and massive PE were analyzed over three years by time period; 102 prior to the use of CBT and 119 during the time CBT was performed. The primary outcome was in-hospital major adverse clinical events (a composite of death, recurrent embolism, major bleeding, or stroke). Secondary outcomes were overall and ICU length of stay and individual components of the composite outcome. Mean age was 56.3±16 years with high rates of central PE (57.9%), RV dysfunction (37%), and myocardial necrosis (26%). Mean RV/LV ratio was 1.2. Thirty-two patients were treated with CBT. The composite endpoint occurred more frequently in the CBT era vs the pre-CBT era (21.0% vs 14.7%, p=0.23). After multivariate adjustment, CBT treatment demonstrated no effect on major adverse clinical events (OR 0.84, CI 0.22-3.22, p=0.80). CBT era patients had an unadjusted 37% increase in ICU days and 54% increase in total length of stay (p<0.001). Within the CBT era, CBT treatment resulted in an adjusted 190% increase in overall length of stay (p<0.001). CBT did not demonstrate improvement in hospital outcomes, despite adjustments of PE severity, and was associated with a significant increase in overall and ICU length of stay.

National trends and outcomes for extra-corporeal membrane oxygenation use in high-risk pulmonary embolism

“…13 Similarly, George et al documented that CDT in 32 patients with massive PE was not associated with improvement in adverse clinical events compared to patients managed without CDT. 4 Ain et al conducted a single-center study and reported survival rates of 58.6% for high-risk PE following the initiation of ECMO, which supports our present data. 14 Meneveau et al conducted a multicenter retrospective analysis to evaluate the outcomes for ECMO use among 52 patients with high-risk PE, 15 reporting a 30-day mortality of 61.5% in patients who underwent ECMO, which was further decreased when surgical embolectomy was employed.…”

“…3 Despite advances in the therapeutic armamentarium, including systemic thrombolytic agents, catheter-directed therapies (CDT), and surgical embolectomy, many patients remain refractory to treatment. 4 Venous-arterial extra-corporeal membrane oxygenation (VA-ECMO) is a promising treatment modality to unload the acutely failing right ventricle (RV). 5 The use of ECMO for high-risk PE has been evaluated only in case series or small retrospective analyses.…”

Retrospective comparison of ultrasound facilitated catheter-directed thrombolysis and systemically administered half-dose thrombolysis in treatment of pulmonary embolism

“…Most have been retrospective analyses and, given lack of power, variations in methodology, and limited study population, no definitive conclusion can be derived on the beneficial role of ultrasound. 15–18…”

Occult Chronic Thromboembolic Disease in Patients Presenting for Surgical Pulmonary Embolectomy

“…Although this tool was constructed in a cohort of patients undergoing surgical embolectomy, its application to aggressive nonsurgical therapies (catheter-based or systemic thrombolysis) should also be evaluated to potentially avoid ineffective and possibly harmful interventions. 19,20…”