Handbook for Venous Thromboembolism

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

“…9 The ideal candidate for CDT has central thrombus (main or lobar) and is stable enough to tolerate a prolonged infusion. 14,15 With systemic thrombolytics, altered hemodynamics may direct a substantial fraction of the therapeutic dose away from the thrombus and into the systemic circulation. 16 The unfavorable safety profile of systemic thrombolytic administration and the surgical morbidity of open embolectomy have made CDT an attractive alternative for the treatment of submassive PE.…”

“…28 The standard infusion rate is 1 to 2 mg/hour for a single catheter or 0.5 to 1 mg/hour if two catheters are in place. The infusion is done in typically 12 to 24 hours, for a total thrombolytic dose of 15 to 30 mg. 14,15 During the thrombolytic infusion, a subtherapeutic infusion of heparin is concurrently administered, with a partial thromboplastin time goal of 40 to 60 seconds. 28 Notably, there is still significant center-to-center variability in dosing and treatment protocols.…”

“…The SEATTLE II study was a prospective, single-arm, multicentered trial designed to evaluate the safety and efficacy of ultrasound-assisted CDT. 15 The study enrolled 150 patients, 119 of whom were classified as submassive and 31 as massive. The primary safety endpoint was major bleeding within 72 hours; the primary efficacy endpoint was reduction in the RV/LV ratio at 48 hours by CT angiography.…”

Intervention in Massive Pulmonary Embolus: Catheter Thrombectomy/Thromboaspiration versus Systemic Lysis versus Surgical Thrombectomy

“…Absolute contraindications include a history of prior hemorrhagic stroke or ischemic stroke within 6 months, central nervous system neoplasm, gastrointestinal bleeding within 1 month or any known active bleeding, or major trauma or surgery within 3 weeks. 15 Low-dose alteplase (50 mg rather than 100 mg) for massive PE may be as effective as the standard dose, with fewer major bleeding events, 16 and could be considered a favorable treatment option in the elderly or frail patient population or those with relative contraindications to thrombolysis. A patient who decompensates into cardiac arrest may no longer have the circulatory support to deliver the thrombolytics to the pulmonary arteries.…”

Achieving Multidisciplinary Collaboration for the Creation of a Pulmonary Embolism Response Team: Creating a “Team of Rivals”

“…17,18 Recently, novel medical, percutaneous, and surgical treatments have become available for the treatment of intermediate-and highrisk PE. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] However, data comparing these treatment options are sparse, and the risks and benefits for an individual patient are difficult to assess. Moreover, different treatment options are favored by different specialties, and in some cases physicians from different specialties can perform the same procedure.…”